Waxing Client Consent Form
Client's Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Gender
Female
Male
Other
Are you under 18? If under 18, please provide your guardian signature
Yes
No
Do you have any allergies? If yes, please mention them:
Do you have any of the following conditions? If yes, please select them:
Metal Implants
Pacemaker or Defibrillator
Epilepsy or Seizures
Open Wound
Cold Sore
Hepatitis A/B/C
HIV AIDS
Blood Clot Disorder
Skin Disease
Hormonal Imbalance
Migraines/Headaches
Eczema
Bruise Easily
Blush Easily
Immune Disorder
Circulation Disorder
Diabetes
Heart Disease
None
Other
How does your skin heal?
Fast
Pigments
Scars
Slow
Other
How often do you use sunscreens?
None
Once a day
Twice a day
More
How often do you apply moisturizer?
None
Once a day
Twice a day
More
Have you had any of the following services within the last 3 months?
Chemical Peel
Chemotherapy
Microdermabrasion
Laser Treatment
None
Have you had any of the following services within the last 2 weeks?
Botox
Filler
None
Are you currently using?
Retin-A
Accutance
AHA
Retinol Derived Products
Blood thinner
None
I am aware that some side effects such as redness, swelling may occur, but these are temporary and will fade after 3 days.
Your Initial
Terms & Conditions
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that all information in this form is true and accurate. I confirm that if I hold some important information and complications happened, the clinic will not be liable. I release this clinic and hold harmless against any claims, expenses, damages, and liabilities.
Client Signature
Guardian Signature if under 18
Date Signed
-
Month
-
Day
Year
Date
Print Form
Submit
Should be Empty: