Waxing Consultation Form

Medical & Skin History

Your privacy is very important. The following information is only used to assess your skin care goals, determine what treatments are appropriate for your skin condition and to avoid any possible reactions.
PLEASE READ!!!!!!

The wax consultation form only needs to be filled out once prior to your first appointment. Owner may ask you to fill out again if there are changes in your health, skin or skincare. Thank you
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Phone:*
ex. 555-555-5555
Birthdate:*
ex. 01/05 Please provide month and day
What is the best way to contact you?*

Phone callEmailTextAll
How did you hear about Gleam?
Are you allergic to anything?*

NOYES
If yes, please list allergies:
Have you had skin cancer?*

NOYES
If yes, please list area(s):
Do you have any permanent cosmetics or tattoos on the areas being treated?*

NOYES
Have you had any of these health conditions in the past or present?

CancerSpinal injuryDiabetesEczemaEpilepsyFever blistersHerpesCold soresImmune disordersHIV/AIDSMetal implantsSeizure disorderSkin diseaseActive Infection
Have you used an acne medication? *

NOYES
Do you currently use any of the following?

Retin-ARenovaAdapaleneDifferinGlycolic AcidAHARetinolAccutaneTazoracRoAccutaneScrubs or PeelsAt home laserAntibiotics
I understand that I must discontinue use of ALL of the above 7 days prior to treatment. Accutane or Roaccutane must be discontinued 1 year prior to treatment.*

YES, I will discontinue.
Do you currently have any rash, windburn, sunburn sensitivites or other issues on the area being treated?*

NOYES
If yes, please explain:
Do you use bleaching creams or Hydroquinone daily?*

NOYES
If yes, please list medication:
Have you had a reaction after having a facial treatment in the past?*

NOYES
Please explain the details:
Have you ever had an ALLERGIC reaction to any of the following?

AHA'sRetinoidCosmeticsSunscreensFragranceLatexTopical RXNONE
Female Clients
Are you pregnant or trying to become pregnant?

NOYES
Any current menopause problems?

NOYES
If yes, please explain:
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Gleam Wax Studio and/or the skin care professional from liability and assume full responsibility thereof.*

I understand the policy.
NO SHOW POLICY- All no call or no text no shows will be charged 100% of the reserved service amount. If you no show two consecutive times you will be restricted from online booking. Future appointments will have to be made by calling the owner to approve booking request. CANCELLATION POLICY - To cancel an appointment you must call or text 201-739-4517 12 HOURS prior to your appointment. You are allowed one, no penalty cancellation a month. After that you will be charged 50% of the reserved service amount. If you cancel three consecutive times you will be restricted from online booking. Appointments will have to be booked and approved by the owner. Late Policy - There is 5 minute grace period with notice only. Anything beyond 5 minutes may be subject to rescheduling, and I do reserve the right to cancel partial or full services time permitting*

I understand the cancellation policy.
OPTIONAL: I grant permission to Gleam Wax Studio to use photos of my progress for marketing purposes on gleamwaxstudio.glossgenius.com or other business listing pages such as Instagram, Facebook, and Google.

I grant permission.
Date*

MonthDayYear
Signature*
Should be Empty:

Medical & Skin History