Essence Skin Bar Wax Consultation Form
Hello! I'm so happy you're here and cannot wait to meet you! Please fill out the consultation forms before you book your appointment with me. For both your safety and mine, I need to make sure that all paperwork is properly taken care of. If consultation forms are not filled out, as stated on my website, I will not perform your service until everything is completed. Thank you in advance and I will see you in my treatment room real soon!
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
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
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Gender
Male
Female
Prefer not to say
Are you 18 years of age or over?
*
Yes
No
How did you hear about me?
*
Instagram
Bare Beauty / Online
TikTok
Referral
Other
If other, please detail:
Medical History
[Do you have a history of any of the following medical conditions or contraindications for waxing? Please select any or all that apply to you.]
*
Rashes
Warts
Blisters/ cold sores
Bleeding disorders
Skin cancer
Chemotherapy / radiation
Diabetes
Recent Botox/Surgery/Face Life
Epilepsy
Eczema
Varicose Veins
Sunburn
Heart condition
MRSA
Keloid Scarring
HIV Positive
Dermatitis
Shingles
Thyroid Issues
Anxiety
Nevus (Birthmarks)
Psoriasis
Accutane
Rosacea
Lupus
Blood Thinning Medication
Other
Do you have any known allergies?
*
Yes
No
If yes, please detail:
List any medications you are currently taking (ex: Accutane, Retin-A, Semaglutide, etc)
*
List any medications you take regularly including vitamins, herbal supplements, asprin:
*
Have you had a waxing treatment done before?
*
Yes
No, First time!
If yes, when was the last time you received a wax treatment and what type was it?
Water Intake
*
0-8oz
8-16oz
16-32oz
32-64oz+
I don't drink water
Other
If other, please elaborate:
Have you ever had a reaction to waxing
*
Yes
No
If yes, what was your reaction?
What areas are we waxing today?
*
Lower Arm
Full Arm
Lower Leg
Full Leg
Full Back
Nasal Wax
Lip Wax
Ear Wax
Underarm Wax
Stomach Strip Wax
Full Chest Wax
Other
Female Clients
When is your next menstrual cycle/ when does it begin?
(Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort you should avoid hair removal two days before your cycle is due and two days after it is completed.)
Are you currently pregnant?
Yes
No
Skin History
Skin Type
*
Ingrown Hair
Scarring
Bumps
Bruising
Hyperpigmentation
Other
What skin products do you regularly use on your skin?
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Are you using Rein-a, Renova, Differin, Tazorac or Accutane?
*
Yes
No
Not Anymore
Are you using any other skin thinning products and/or drugs?
*
Yes
No
Not Anymore
Do you use a tanning bed?
*
Yes
No
Are you exposed to the sun on a daily basis?
*
Yes
No
Is there anything else that you want me to know before providing you with your wax service to make it more comfortable or beneficial for you?
I understand that I can be exposed to chemicals that are used for beauty and cosmetic benefits.
*
Yes, I understand
Photo & Video Release:
I hereby give Essence SkinBar permission for any photos, videos, or audio that are taken of me to be used in and/or for any lawful promotional materials, such as but not limited to newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media pages, and other print and digital communications.This authorization shall continue indefinitely and extends to all languages, media, formats and markets now known or later discovered.I renounce all claims I may have to royalties or other forms of payment resulting from or connected to the use of the image or sound recording.I understand and agree that these materials shall become the property of Essence SkinBar and will not he returned. By signing below, I hereby acknowledge that I have completely read and fully understand the above release agreement. In addition, I understand that I will not receive financial compensation for photos or videos that may be taken during this facial treatment.
*
Yes, I understand and agree.
Terms and Conditons
I understand that my data will be strictly confidential. This clinic does not sell, share, or resell information. I confirm that if I withhold some important information from Essence SkinBar and complications happen, the clinic will not be liable. I fully read and understand the cancellation, no-show and rescheduling policies. I release Essence SkinBar and hold harmless against any claims, expenses, damages, and liabilities. I understand that by booking and entering my card information, I am authorizing Essence SkinBar to charge my card fees associated with no-show and late cancellation policies. I understand that I can view cancellation policy details on Essence SkinBar's website.
*
Yes, I understand and agree.
Name
*
First Name
Last Name
Enter today's date:
*
-
Month
-
Day
Year
Date
Submit
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