Waxing Form

Waxing Form

Please answer the questions below to help us provide the best service.
Today's Date

MonthDayYear
DateHourMinutesAM/PM Option
Full Name*
Please type first and last name.
D.O.B. (MM/DD/YYYY)*
Phone*
Email Address*
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
How often do you wax?
Do you have any allergies?

YESNO
If yes, please explain...
Are you on any medications?

YESNO
If yes, please explain...
Have you been or will be in the sun (or tanning bed) within 24 hours of this treatment?

YESNO
Have you had any dermabrasion treatments?

YESNO
If yes, please explain...
Have you had BOTOX treatments in the last 72 hours?

YESNO
If yes, please explain...
Are experiencing dry skin?

YESNO
Are you using any acne/skin medications?

YESNO
If yes, please explain...
Are you pregnant?

YESNO
If yes, what's your due date?
Do you have diabetes, phlebitis, or any skin irritations?

YESNO
If yes, please explain...
Do you have any of the following in the wax treatment area?

Breakouts/AcneSun DamageDull/Dry SkinRosaceaBroken CapillariesNone
Post Waxing

To ensure maximum comfort and benefit after the treatment, it is important to follow the steps below at home:

• Avoid applying heat to the waxed area for 12-24 hours. This includes hot baths, sauna, and steam.

• Use an anti-acne lotion on the treated area following the treatment and twice a day until breakouts are gone.

• Avoid sun tanning for 12-24 hours. This includes any strong ultraviolet (UV) light exposure or tanning bed treatments.

• Avoid applying highly fragrance products to the waxed area. This includes perfume, scented body lotions, anti-perspirants, cosmetics, or feminine hygiene sprays.

• Avoid using harsh abrasive or exfoliates in the waxed area. If you are prone to in-grown hairs, the day after your waxing treatment, exfoliate newly waxed area with a loofah to avoid future problems.

• Avoid applying SPF sunblocks to the waxed area for 12-24 hours after the waxing service. Suncreen chemicals can be irritating to the newly waxed skin. This includes self tanning products and tan acceleraters.

For best results, repeat your professional waxing every 4-6 weeks depending on the area and your individual hair growth rate.
This consultation form is completely confidential. Completion of the form gives the general state of health and assists our specialist in directing a customized course of treatment for your individual skin care needs. We will not provide this information to anyone else, except as required by law, and we will not sell this information to anyone. We may, however, contact you with product related information.
I confirm (to my best knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history. I also understand the post treatment home care instructions. I understand how important it is to follow all instructions given to me for post treatment care.
Client Signature*

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