Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
-
Month
-
Day
Year
Date
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
*
Are you using any other skin thinning products and/or drugs that thin the blood?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
*
Yes
No
I understand that photos and/or videos may be taken during services. Please note that all client identities will be classified.
*
I Agree
I Disagree
Are you currently taking any medications? If so, please list.
*
Have you been treated for cancer? If yes, when and what types of therapies were used?
*
Please list any illness/conditions which ou are currently being treated for by a medical professional.
*
Do you have any open skin lesions?
*
Yes
No
Do you have any allergies? If so, please list.
*
What is your favorite music artist?
*
Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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