Waxing Intake Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Phone#
*
Format: (000) 000-0000.
Email
*
example@example.com
Occupation
Emergency Contact Name
Phone#
Format: (000) 000-0000.
How did you hear about us?
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Waxing Health & Skin Screening
What area(s) are being waxed today?
Brows
Upper Lip
Chin
Underarms
Other
Are you currently using Retin-A/tretinoin, retinol, retinal, adapalene, tazarotene, or another topical retinoid on or near the area being waxed?
*
Yes
No
Are you currently taking, or have you recently taken, Accutane/isotretinoin?
*
Yes
No
If yes, when was your last dose?
Have you used AHA/BHA acids, glycolic acid, salicylic acid, exfoliating products, scrubs, or other strong active skincare on the area within the past 5–7 days?
*
Yes
No
Have you recently had a chemical peel, laser treatment, microneedling, dermaplaning, microdermabrasion, or other resurfacing treatment on the area?
*
Yes
No
Are you using any prescription medication, topical medication, or skincare product that causes thinning, peeling, sensitivity, or delayed healing of the skin?
*
Yes
No
Do you currently have sunburn, broken skin, cuts, abrasions, rash, irritation, infection, eczema, psoriasis, or dermatitis in the area being waxed?
*
Yes
No
Have you recently had significant sun exposure or used a tanning bed?
*
Yes
No
Have you ever experienced skin lifting, tearing, bruising, excessive swelling, or another significant reaction from waxing?
*
Yes
No
Do you have any known allergies or sensitivities to wax, rosin/colophony, latex, adhesives, skincare products, or topical products?
*
Yes
No
Do you have diabetes, a bleeding disorder, impaired wound healing, or another medical condition that may affect your skin or healing?
*
Yes
No
Are you taking blood thinners or medications that may increase bruising or bleeding?
*
Yes
No
For underarm waxing: Have you applied deodorant, antiperspirant, acids, exfoliants, retinol, or other potentially irritating products to the area today?
*
Yes
No
Is there anything else about your skin, medications, allergies, recent treatments, or health that your esthetician should know before waxing you?
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Consents
I acknowledge:
*
I understand that waxing removes hair from the follicle and may cause temporary redness, tenderness, swelling, irritation, bruising, follicular irritation, or breakouts.
I understand that waxing carries a risk of skin lifting, tearing, burns, hyperpigmentation/hypopigmentation, ingrown hairs, infection, or allergic/sensitivity reactions.
I understand that certain medications, skincare ingredients, exfoliation, cosmetic procedures, and sun exposure can make my skin more susceptible to injury from waxing.
I confirm that I have disclosed all relevant medications, topical products, skin conditions, allergies, and recent treatments.
I understand that my esthetician may modify or refuse to perform the service if my skin appears compromised or waxing would be inappropriate.
I understand that individual skin reactions and results vary and that a specific result cannot be guaranteed.
I agree to follow the aftercare instructions provided to me.
I have had the opportunity to ask questions and voluntarily consent to the waxing service.
By signing below, I acknowledge there is a no-refund policy in place. By paying for my service at the completion, I am acknowledging that I am satisfied with my services provided and credit card disputes will then be considered frivolous.
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.
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Take Photo
*
Name Printed
*
Signature
*
Submit
Geolocation
*
Should be Empty: