Elena G Beauty
Wax Intake Form
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age?
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Medical History:
Do you have any allergies?
Yes
No
If yes, please list them.
Do you have any skin conditions (e.g., eczema, psoriasis, rosacea)?
Yes
No
Do you have any chronic medical conditions (e.g., diabetes, heart condition)?
Yes
No
Are you using any other skin thinning products and/or drugs that thin the blood?
Yes
No
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.
Are you currently pregnant or breastfeeding?
Yes
No
Have you had any recent surgeries or cosmetic procedures (e.g., Botox, Chemical Peels)?
Yes
No
If yes, please provide details:
Skin and Hair History
What is your skin type?
Oily
Dry
Combination
Sensitive
Normal
Do you use any skincare products containing retinoids, AHAs or BHAs?
Yes
No
If yes, please provide details:
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year?
Yes
No
Have you had waxing done before?
Yes
No
If yes, how was your experience?
Do you have a history of ingrown hairs or irritation after waxing?
Yes
No
How do you typically remove hair?
Shaving
Waxing
Depilatory creams
Any other way, please share?
Lifestyle Questions
Are you currently using any tanning beds or self-tanners?
Yes
No
Do you exercise regularly or use saunas/steam rooms?
Yes
No
Are you exposed to the sun on a regular basis?
Yes
No
Do you have any upcoming special event or plans that require specific attention to your waxing results?
Yes
No
If yes, please describe?
Consent and Understanding
Do you understand that waxing can have certain side effects such as skin removal, temporary redness, swelling, tenderness, or irritation, etc?
Yes
No
Do you have any specific concerns or questions about your waxing service?
Please acknowledge your understanding of the waxing service and agree to adhere to safety post care instructions
I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: