Waxing Consultation Form
Client information
Name
First Name
Last Name
Date of birth
-
Month
-
Day
Year
Date
Preferred Pronouns
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about me? (Social Media, friends, etc)
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Medical History
Do you have or have day any of the following conditions?
If yes, please select them:
AIDs/HIV
Eczema/Psoriasis
Cold Sores/Fever Blister
Hepatitis
Herpes
Varicose Veins
Cancer
Diabetes
Other skin irritation
None
Have you ever been treated for cancer?
Yes
No
If yes, what type of therapies were used?
Any known allergies?
Yes
No
List any medications you take regularly (including vitamins, herbal supplements, aspirin)
Are you pregnant?
Yes
No
Any other medical conditions or illness I should be aware about?
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Skin History
Do you have any tendencies to:
Ingrown hair
Scarring
Bruising
Bumps
Hyperpigmentation
Do you have sensitive skin?
Yes
No
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?
Yes
No
Are you using Retin-a, Renova, or Accutane?
Yes
No
Are you using any other skin thinning products and/or drugs. (BHAs, benzoyl peroxide, retinol, salicylic acid)
Yes
No
Are you exposed to the sun on a daily basis. (Is your job outside, are you constantly spending your time outside etc)
Yes
No
Do you plan on spending more time in the sun soon? (Tanning, hikes, etc)
Yes
No
Do you use tanning beds?
Yes
No
Have you ever had a waxing treatment before?
Yes
No
Have you ever had a reaction to waxing?
Yes
No
If yes, what happened?
What skin products do you use regularly on your skin?
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By signing below, you agree to the following:
I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities towards my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
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Client Consent Form
I hereby consent to and authorize
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to perform the following procedure:
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Please check each statement:
I am aware of side effects including, but not limited to: allergic reaction, irritation, redness, burning, swelling, soreness, bruises or bumps.
I am aware certain medications and over the counter products can increase the risk of injury when combined with skin care services. I am not using any medications that may cause such injury/reaction. I will advise my esthetician if this changes.
I have been off of Accutane for at least 12 months and I am not using Retin-A, any products contacting alpha hydroxyl, or doing any other skin thinning treatments for the past 72 hours.
I have not used a scrub, take home micro-dermabrasion, glycolic peels, other peels, exfoliated or tanned in the last 72 hours.
I do not have any open skin lesions or active herpes outbreak (cold sore or genital).
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 have the right to refuse services for all waxing if proper hygiene is not followed.
I am over 18 years of age or I have parental consent co-signed below.
I give the technician permission to photograph the area to be waxed for marketing and promotional purposes
I understand that waxing does not permanently remove the hair and upkeep is necessary to see results.
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications.
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
I understand that if I have any concerns, I will address with my technician.
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My signature acknowledges that I have read and agree to receive the treatments or series of treatments listed above and that I will adhere to all of the aforementioned statements that I have initialed. I fully understand the risks and side effects associated with the treatment. I freely assume these risks and release the provider and the Esthetician of all liability.
Signature
Submit
Submit
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