Waxing Consent Form

Waxing Consent Form

Esthetics With Me
Name

First NameLast Name
Email
example@example.com
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:
Today's Date

MonthDayYear
Date
Do you have instagram?

YesNo
What is your instagram handle?
How did you hear about us?

GoogleFacebookInstagramReferralOther
If referred, by who?
When is the last time you waxed or shaved the area(s) intended to be waxed?
Did you wax or shave?

WaxShaveN/A
Have you ever experienced itching post hair removal?

YesNoSometimes
If yes, was it due to ingrowns, dryness, or sensitivity?
Don't worry! We will talk more about this in person :)
Have you ever been waxed before?

Nope - first time!Yes - within the last yearYes but it has been a while
Is this wax only for a special occasion? If so - when is the occasion?
Do you experience ingrown hairs?

YesNoNot sure
Where do you experience ingrowns and are they painful for you?
Are you currently doing anything to help your ingrowns or what have you tried in the past? Has anything ever helped or made it worse?
Have you taken Accutane in the past year?

YesNo
Are you using Retin-A, Differin, or Renova?

YesNo
Are you taking medications that make you photo sensitive?

YesNo
Do you frequent tanning beds?

YesNo
*If you choose to frequent tanning beds please avoid tanning 3 days before AND 3 days after waxing
Are you currently sunburned?

YesNo
Are you diabetic?

YesNo
Are you on blood thinners?

YesNo
If you are currently using any of the following medications you cannot get waxed today. Select any that you are CURRENTLY taking.

AccutaneAdapaleneIsotretinoinRetin-ARenovaAlustraAvitaTazaroteneTretinoinAvageDifferin
Do you currently have or have had any of the following medical conditions that could compromise your skin and/or services being offered:

AIDS/HIVHepatitisVaricose VeinsEczema/PsoriasisHerpesCancerCold Sores / Fever Blisters
Tips To Prepare For Waxing by Esthetics With Me

First time? Make sure hair is grown out at least 10-14 days before your appointment. If you currently don't shave - there is nothing you need to do before your appointment.

1. If you are nervous about discomfort - take an ibuprofen 30-40 minutes before your appointment.

2. Wear loose fitting clothing to your appointment & for the rest of the day.

3. NO swimming or exercising 48 hours post wax. It is popular to get waxed right before leaving for vacation - It is advised to get waxed 3 days before you leave town.
You may experience skin sensitivity / thinning, which can result in skin lifting, from the following: sunburned skin, retinol, certain medical conditions, pregnancy, antibiotics, other medications not listed, or menstruation.

I understand the risks and dangers of waxing and agree to hold harmless Esthetics With Me of all liability in relation to the service being provided. I agree if I begin use, or are currently using, any of the products listed in the above warning and do not inform Esthetics With Me prior to current or future treatments, I accept full responsibility for any adverse reactions.

It is understood that waxing may cause some redness, bumps, soreness, and/or itching.
I acknowledge that I must adhere to Esthetics With Me policies. I understand that cancellations must be done with at least 48 hours notice. Any cancelations within less than 48 hours of notice are subject to a cancelation fee amounting to 35% of your scheduled service. Clients who miss their appointments without giving any prior notification will be charged in full for the scheduled service. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.
Signature
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