Waxing Intake/Consent Form
Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Appointment Date:
-
Month
-
Day
Year
Date
PersonalInformation:
Are you 18 yrs or older?
*
Yes
No
Will this be your first time waxing?
*
Yes
No
If no, did you have any reactions after or during waxing?
*
Yes
No
Are you pregnant?
*
Yes
No
Medical History:
Any chemical exfoliation treatment such as glycolic acid peel or any other treatment within the last 2 weeks on the area being waxed?
*
Yes
No
If you did have any chemical peel, when did youhave it done:
Applied any topical products containing AHA's, BHA (salicylic acid), lightening or bleaching gels within the last 48hrs?
*
Yes
No
Have you had a microdermabrasion, laser, light therapy or injectables/botox within the last 4 weeks?
*
Yes
No
Are you currently taking any Retin-A or vitamin A products within the last 3 months?
*
Yes
No
Within the last 6 months have you taken Accutane?
*
Yes
No
If you have taken Accutane, when was the lasttime you did?
Are you using any other skin thinning products and or drugs?
*
Yes
No
Seen or seeing a dermatologist?
*
Yes
No
Have you been treated for cancer?
*
Yes
No
Do you have any of the following?
*
HIV/AIDS
Eczema
Cold sore/blisters
Hepatitis
Herpes
Varicose Veins
Cancer
Diabetes
Other Skin Irritation
None
Skin History:
Do you have any tendencies to?
*
Ingrown hair
Bruising
Bumps
Scarring
Hyperpigmentation
None
Have you tanned within the last week?
*
Yes
No
Have you tanned within the last week?
*
Yes
No
Allergic to any scents? Example Lavender, Aloe, etc. If none jut type in "NONE
*
Yes
No
Are you allergic to latex gloves?
*
Yes
No
Do you have any sensitivity or allergies?
*
Yes
No
Terms &Conditions
Please be aware, prior to waxing if the skin shows any signs of irritation, rash or broken skin I will not wax.
*
Yes, I understand and agree.
I understand that Elsa my esthetician has the right to refuse to provide services if proper hygiene is not followed.
*
Yes, I understand and agree.
I confirm that I do not have any open skin lesions or an outbreak of herpes.
*
Yes, I understand and agree.
I give permission to Elsa to perform the waxing procedure I have scheduled and will NOT hold her from any liability that may result from this treatment.
*
Yes, I do give Elsa Permission.
I have given accurate account of questions above including all known allergies or prescription drugs or products I am currently on.
*
Yes, I have given the correct information regarding my health.
I am aware that waxing may have some side effects including, but not limited to redness, scabbing, bruising, scarring, swelling, tenderness, hyperpigmentation, flaking, and or pimples.
*
Yes, I understand and aware.
I am aware that discomfort may occur, if discomfort persists, I am to contact Elsa a medical professional at my own expense.
*
Yes, I understand and agree.
I agree to follow the post care instructions, and failure to follow these instructions may results in irritation, ingrown hairs, bacterial infections, rashes, itching, redness, and/or scarring.
*
Yes, I understand and agree.
I understand and agree not to bring any guests to my appointment.
*
Yes, I understand and agree.
I understand and agree to reschedule/cancel my appointment 24 hrs before my scheduled appointment.
*
Yes, I understand and agree.
I agree that I have read and fully understand the above statements and have answered the above questions truthfully.
*
Yes, I understand and agree.
I understand and agree that this agreement will remain in effect for this procedure and all future procedures completed by Elsa for up to a year.
*
Yes, I understand and agree.
I use Instagram (@bareskinglowstudio) for promotional proposes. Do you consent photos/videos during your service?
*
Yes
No
By signing below, I agree to the following:I have completed this form to the best of my ability and knowledge. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform Elsa (Bare Skin Glow Studio) of any discomfort I may experience at any time during my treatment to allow her to adjust accordingly. I agree to waive all liability toward my technician Elsa (Bare Skin Glow Studio) for any injury or damages incurred due to any misrepresentation of my health.
Today's Date:
-
Month
-
Day
Year
Date
E-Signature:
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