Waxing Consultation Form

Waxing Consent Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you ever had your hair waxed by a professional?

YesNo
Have you ever had a problem with waxing? (e.g. allergic reaction)

YesNo
In the last 48 hours, have you had a peel, microdermabrasion, or tanned?

YesNo
Do you have a problem with ingrown hairs?

YesNo
Do you have any allergies?

YesNo
Have you used these or any anti-aging/ acne treatment products in the last 7-14 days?

RetinoidsBenzoyl PeroxideHydroquinoneTopical SteroidsOther
Have you used Accutane/ oral Isotretinoin in the last 6-12 months?

YesNo
Please list all your allergies/allergens.
Are you on any medications right now? If yes, please specify.
If any of the factors listed above are present, you may suffer higher discomfort as well as an increased risk of side effects such as skin damage, bruising, scabbing, or other complications. If any of the above items change between visits, you must notify your practitioner promptly. For your safety during hair removal or other services, keep your intake information up to date.
When was the last time you shaved or waxed?

MonthDayYear
Date
Please choose the waxing service you want:

LipBrowsChinSideburnsFull armHalf armUnder armsBackFull faceFull legHalf legFull BrazilianBikini
I consent to have my picture or video of myself used for social media purposes.

yesno
I understand that if I start or continue to use any of the products indicated above without informing the esthetician student prior to current or future treatments, I assume full responsibility for any negative responses. I'm aware that the operation may result in redness, lumps, pain, or irritation.
Signature
Date

MonthDayYear
Date
If necessary:
Parent/ Guardian Signature
Date

MonthDayYear
Date
LHA Student Signature (please hand form to them to sign)
Should be Empty:

Waxing Consent Form