Waxing Intake Form & Liability Waiver

Waxing Intake Form & Liability Waiver
For the comfort and safety of both client and esthetician, Brazilian/bikini services are exclusively for female anatomy.

Men’s services include brows, nose, and ears only.
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Have you used any of the following within the past year?
- Accutane (Acne medication) – You must be off this medication treatment course a minimum of one (1) year prior to waxing.
- Adapalene (Acne medication)
- Alustra (Retin A)
- Avage (See Tazorac – Acne medication)
- Avita (See Retin A)
- Differin (Acne medication)
- Isotretinoin (See Accutane)
- Renova (See Retin A)
- Retin A (Acne and Anti-aging medication)
- Tazarac (Acne medication)
- Tazarotene (See Tazorac)
- Tretinoin (See Retin A)
Select One:*

YesNo
If Yes, when?
Are you using any other skin thinning products and/or drugs that thin the blood?

YesNo
Are you currently taking any medications such as steroids or antibiotics? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any illness/conditions which you are currently being treated for by a medical professional.
If you are currently using any of the following, please select all that apply. (These products can make the skin more sensitive. Thin, sensitive skin is more vulnerable to lifting and sensitivity during waxing.)

Other Acne medications not listed aboveBleaching agents for hair (used mostly for upper lip)Bleaching agents for pigmentation of skin (Hydraquinone, Trilumena)Previous chemical depilatories such as NairBenzoyl PeroxideAlpha Hydroxy Acids (Glycolic, Lactic)Oral AntibioticsTopical AntibioticsRetinolSalicylic AcidOther exfoliants
Do you use tanning beds and/or are exposed to the sun on a regular basis?

YesNo
Do you have any open skin lesions?

YesNo
Are you pregnant?

YesNo
Do you have any allergies?

YesNo
Please list your allergies
Precautions & Considerations
- Sunburned, irritated or areas with open skin cannot be waxed.
- Moles cannot be waxed.
- You must wait a minimum of seven (7) days before waxing after a light chemical peel or Microdermabrasion.
- Waxing cannot be performed if you have been in a tanning booth the same day.
- Waxing cannot be performed if you have had laser skin resurfacing within the past year.
- Waxing cannot be performed if you have had a physician administered peel within the past two (2) years.
- Waxing cannot be performed if you have had botox within the past two weeks.
- No sun/tanning booths for 2 days following a waxing treatment. Extra precaution should be taken if using tanning accelerators. Wait 2-3 days to wax before/after tanning with accelerators.
- No hot baths for 24 hours following a body waxing treatment.
- No abrasives for 24 hours following a waxing treatment.
- No sweating/working out for 24-48 hours following a waxing treatment.
- Women may experience extra sensitivity to waxing up to a week prior to the beginning of their menstrual cycle.
- Waxing can have certain side effects such as skin removal, redness, swelling, skin irritation, tenderness, bruises, or bumps, etc.
Acknowledgement
*

I have provided accurate information about my medical history, including any medical conditions, medications, allergies, or skin sensitivities. I understand that it is my responsibility to inform the esthetician of any changes in my health, medications, and product use before each waxing session. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. I understand that the esthetician will take all reasonable precautions to minimize the risk of adverse reactions. I agree to follow any pre- and post-waxing care instructions provided by the esthetician to ensure the best results and reduce the risk of complications. By signing below, I acknowledge that I have read and understood the risks and potential side effects associated with waxing. I voluntarily consent to the waxing treatment and release the esthetician and the establishment from any liability in case of any complications arising from the treatment.
18 and Over Certification*

I confirm that I am 18 years of age or older and acknowledge the risks and procedures of the waxing treatment as outlined in this consent form.
Electronic Signature Agreement: By typing my first and last name below, I acknowledge that my electronic signature holds the same legal validity as my handwritten signature. I understand and accept the terms outlined in this form.*
Date

MonthDayYear
Date
Signature *
Email
example@example.com
Should be Empty:

Waxing Intake Form & Liability Waiver

Precautions & Considerations

Acknowledgement