Client Intake Form

Client Intake Form

Thank you for your interest in booking with me. Please fill out prior to booking your appt. I look forward to seeing you! Questions? Please text 423-430-6998. Book your appt online at https://waxedjc.com
Name*

First NameLast Name
MaleFemale
Date of Birth*

MonthDayYear
Date
Phone Number*
Format: (000) 000-0000.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact*

First NameLast Name
Emergency Contact #*
Please enter a valid phone number.Format: (000) 000-0000.
Occupation*
How were you referred to us? (Google/Yelp/Online, Facebook/Instagram, Friend/Family Member)*
What would you like to achieve from your treatment today?*
CancerHypertensionHypotensionMetal ImplantsPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsNoneOther
NormalOilyDryAcneDehydratedAgingSensitiveRosaceaCombination
FastPigmentsScarsSlowOther
YesNo
YesNo
When?
If yes, please specify when and what treatment:
YesNo
Type 1- Fair skin tones—Always burns, never tansType 2- Light skin tones—Burns easily, tans slightlyType 3- Fair to olive skin tones—Burns moderately, tans moderatelyType 4- Light brown skin tones—Burns slightly, tans easilyType 5- Dark brown skin tones—Rarely burns, tans easilyType 6- Dark brown to black skin tones—Never burns, tans easily
YesNo
If yes, please specify:
YesNo
YesNo
YesNo
If yes, please specify what and when last used:
YesNo
If yes, when and what medication?
YesNo
If yes, please specify what and last use:
Please list ALL medications, supplements, or herbal remedies you currently take:*
Please list allergies or sensitivities:*
YesNo
If yes, please specify:
YesNo
ShavingStringingWaxingDepilatoriesElectrolysisPlucking/TweezingNoneOther
YesNo
Breakouts/acneSun damageRosaceaFlaky skinSun/liver/brown spotsUneven skin toneExcessive oil/shineDull/dry skinRedness/ruddinessBlackheads/whiteheadsWrinkles/fine linesBroken capillariesDehydratedNoneOther
DehydratedDark circlesWrinklesPuffinessNoneOther
DehydratedCracked/chapped lipsNoneOther
CosmeticsFragranceAnimalsDrugsAHAsFoodLatexIodineMedicationShellfishSunscreenPollenNoneOther
What SPF do you use on your face? *
How often/when?*
YesNo
If yes, please specify:
YesNo
If yes, please specify:
< 1 glass1-3 glasses4-7 glasses8+ glasses
None1-23-56+
I don’t drink1-34-78+
YesNo
< 33-56-88-1010+
FruitsFishVegetablesGrains/BreadDairy/EggsProcessed sugarCheeseProcessed meatsPoultryRed meat
YesNo
Never1-2 times/year1-2 times/quarterMonthlyWeekly
< 3 hours4-6 hours7-9 hours12+ hours
YesNo
YesNo
What are your stress levels on a scale from 1 to 5 (1 = low stress, 5 = high stress)?*
YesNo
YesNo
YesNo
YesNo
If yes, please specify:
YesNo
If yes, please specify:
YesNo
If yes, please specify:
YesNo
YesNo
If yes, please specify:
What beauty or cosmetic products are you currently using? Please list all:*
Are you taking any medications that are related to cosmetic or skin improvement?*
Please submit 3 photos of only your full face in frame taken in natural lighting with no makeup applied. (*Facial clients only. Left side , center, and right side)

Cancelof
YesNo
I just want to relaxSome conversation is okI love to talk
What music would you prefer to listen to during your service?*
YesNo
I hereby consent to and authorize the technician/aesthetician to perform the booked treatment/procedure.I agree to cease use of retinols, retinoids, AHAs, BHAs, or any actives 7-10 days prior to receiving a waxing and/or facial service.I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure has been explained to me, along with the risks and hazards involved.Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me. In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/aesthetician immediately. l understand that if I choose to consult a physician, I do so at my own expense.I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, and medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.I understand, THROUGH NO FAULT OF MY AESTHETICIAN, waxing may make me more vulnerable to contracting Folliculitis which is a common condition in which hair follicles become inflamed. Severe infections can cause permanent hair loss and scarring. Mild cases will likely clear in a few days with basic self-care measure.I understand once this form is submitted, I must return to www.waxedjc.com to book my appointment.
Terms & Conditions
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/aesthetician/skin care professional from liability and assume full responsibility thereof. I understand that if I have any concerns, I will address these with my technician/aesthetician. I give permission to my technician/aesthetician to perform the above treatment/procedure we have discussed and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand my technician/aesthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/aesthetician responsible for any of my conditions that were present, but not disclosed at the time of this procedure that may be affected by the treatment performed today.

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive facials/body spa treatments, lash/brow and/or waxing services.
2) I understand that the therapist or aesthetician does not diagnose illnesses or injuries, or prescribe medications.
3) I have clearance from my physician to receive facials, waxing services and/or massage therapy.
4) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Short-term muscle soreness
• Exacerbation of undiscovered injury

• Pinpoint bleeding
5) I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let the aesthetician know
about any changes to these. I understand that there may be additional risks
based on my physical condition.
6) I understand that it is my responsibility to inform my aesthetician of any discomfort I may feel during the session so he/she may adjust
accordingly.
7) I understand that I or the therapist or aesthetician may terminate the session at any
time.

POLICIES

All appointments require a 50% non refundable deposit to book. If you cancel/reschedule without a 24 hour notice, you forfeit your deposit, and another 50% deposit will be required to reschedule. If you need to reschedule, please do so before the 24 hour window and your deposit will be transferred to your rescheduled appointment. All no shows will not be able to reschedule and forfeit their deposit. Missed appointments are responsible for 50% of their scheduled service(s). We will charge the card on file or send you an invoice to be paid promptly. By signing this contract, you are agreeing to being held responsible for past due charges.

Please do not bring guests to your appointment, this includes children. For safety and liability purposes, only the individual receiving the service is allowed in the treatment room. The only exception to this is for minors being accompanied by an adult. ALL minors must be accompanied by a parent/guardian. NO minor will be able to receive brazilian waxing. Thank you for understanding.

Please DO NOT wear makeup to your lash/brow/facial appointment as this takes away from the full time of your service.

Please note: card payments will incur a 4% convenience fee.

Thank you!
Please type your full name below *
Client Signature*

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Parent/ Guardian Signature if Client is a Minor

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Date Signed*

MonthDayYear
Date
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Client Intake Form

Terms & Conditions