Beauty Culture - Wax form

Client Intake and Consent - Waxing
Name
Email
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Have you used any Alpha or Beata Hydroxy acids in the past 48-72 hours? *

yes no
Are you using Retin-A, Renova, or Accutane? *

Yes No
Are you using any other skin thinning products or drugs? *

Yes No
Do you use a tanning bed? *

Yes No
Are you exposed to the sun on a daily basis? *

Yes No
Are you diabetic? *

Yes No
Do you suffer from shaving irritation? *

Yes No
Are you pregnant/nursing? *

Yes No
Are you currently taking any medications? If so, please list all including over the counter drugs/ herbal supplements.
What skin products do you regularly use?
Have you ever been treated for cancer? *
Please list any other illness/ condition you are currently being treated for by a medical professional
(Female clients) when is your next menstrual cycle due to begin?

Month Day Year
Date
Policies
- We require all clients to have a card on file.
- Please notify Body by Bemily 48 hours in advance of any cancellations or rescheduling - which may also be done directly through Square.
- No-shows will be charged a $45 fee.
- By signing below, I give permission to Body by Bemilly, LLC to charge the card on file for any no shows and last minute cancellations.
Return Policy
- Products purchased in the Spa must be returned within 7 days of purchase and the products being returned must be unopened.
- Products that have been opened and are returned will not be refunded.
For any questions, please text us at (774)294-0432.
Acknowledgement *

I understand the my esthetician is a trained professional and will do everything to provide me with the best results and taking every precaution to minimize or eliminate negative reactions. I understand that waxing may have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have provided all answers above to the best of my knowledge. I am willing to follow recommendations made by my esthetician for a home care regimen. I allow Body by Bemilly to take photographs of my before and after results of certain procedures as proof of the treatment. If you do not wish to take photographs, we have the right to decline to serve you. I allow Body by Bemilly to use these photographs for case studies, advertising and marketing. I acknowledge that I have read and agree with the above polices and policies located on Body By Bemilly website.
Signature *

Clear
Date

Month Day Year
Date
Should be Empty:

Now create your own Jotform - It's free! Create your own Jotform

Client Intake and Consent - Waxing