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
  • Gender*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you have any of the following conditions? If yes, please select them:*
  • Skin condition*
  • How does your skin heal?*
  • Does your job require you to work outdoors, or are you frequently in the sun/use the tanning bed?*
  • Have you ever had a facial treatment before?*
  • Have you ever been waxed before?*
  • Which of the following best describes your skin type? (Please check one)*
  • Do you have any special skin problems or concerns pertaining to your face or body?*
  • Have you ever had chemicals peels, laser treatments, or microdermabrasion?*
  • In the last month?*
  • Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivativeproducts?*
  • Have you used acne medication?*
  • Have you experienced Botox, Restylane, or collagen injections?*
  • Do you have any underlying medical conditions your provider should be aware of?*
  • Have you used any hair removal methods in the past six weeks?*
  • Check all that apply*
  • Do you experience ingrown hairs as a result of hair removal?*
  • What areas of concern do you have regarding your: Skin (Check all that apply)*
  • Eyes (check all that apply)*
  • Lips (check all that apply):*
  • Have you ever had an allergic reaction to any of the following (Check all that apply):*
  • Have you recently used any self-tanning lotions, creams or treatments?*
  • Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
  • How many glasses of water do you drink per day?*
  • How many caffeinated beverages (coffee, tea, soda, etc.) do you consume per day?*
  • How many alcoholic beverages do you consume per week?*
  • Are you vegan?*
  • How many hours of sleep do you get per night?*
  • Which foods do you consume on a regular basis?*
  • Are you currently under any kind of diet?*
  • How often do you travel on a plane?*
  • How many hours do you spend in front of a screen or digital device?*
  • Do you exercise on a regular basis?*
  • Do you smoke cigarettes, vape, or consume other tobacco products?*
  • Are you pregnant?*
  • Are you trying or planning to be pregnant?*
  • Are you breastfeeding?*
  • Are you taking any contraceptive pills?*
  • Are you experiencing any menopausal symptoms?*
  • Are you undergoing any hormone replacement therapy treatments?*
  • Are you wearing contact lenses?*
  • Have you undergone any surgeries?*
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  • Do you give permission for photos to be taken and shared on social media of your service? (Please note: pics are NEVER taken during waxing sessions of intimate areas)*
  • How much conversation would you prefer during your service?*
  • May I call and/or text you at the provided phone number to confirm future appointments?*
  • Please check all boxes below.*

  • 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!

  • Date Signed*
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