Waxing Consent & Intake Form-Wax.byKayla

Waxing Consent & Intake Form

Black Cat Waxing Co.
WAXBYKAYLA LLC
Name*

First NameLast Name
Email
example@example.com
Date of birth*

MonthDayYear
Date
Gender*

MaleFemaleNon-binary
Phone Number*
Please enter a valid phone number.
Have you had waxing treatments previously?*

YesNo, this is my first time waxing
Have you suffered from any negative or adverse reaction to waxing previously?*

YesNo
Have you used any AHAS (Alpha Hydroxy Acids), Glycolic or Salicylic products in the last 24-48 hours where you will be getting waxed?*

YesNo
Are you actively using Retin-A, Renova, Differin, Accutane or ANY other acne medication?*

YesNo
If Yes, please specify which product and when was the last time applied topically or taken orally?:
Are currently taking an antibiotic orally or topically?*

YesNo
Please check any health conditions or choices below that pertain to you currently.*

AllergiesDiabetesHigh/low blood pressureVaricose veinsHeart conditionHaemophiliaEpilepsyRadiotherapyPsorasisPredisone/SteroidsBlood thinnersChemotherapy/RadiationRecent laser skin treatmentNone of the above
Are you/could be pregnant and/or breastfeeding?*

YesNo
Why am I being asked all of these questions? I've never had to answer these for a wax before!

My answer is that: I simply care about your skin :)!!!

Your Esthetician/waxer should ALWAYS ask you questions regarding your skin to give you quality results and avoid things like skin lifting during a wax.

Also, what is skin lifting?

Skin lifting is: when a layer of the skin is unintentionally removed during waxing. This causes irritation, redness, & small lesions. This can occur due to many reasons including wax temperature and mainly due to all of the contraindications listed throughout this form.

As your Esthetician, I will always use proper techniques and correct waxing temperatures to avoid this from happening. All I ask is that you answer all of the questions on this form honestly, to avoid this from occurring.

**Not my photo: just an example from Google.
Precautions & Considerations
Waxing cannot be performed if:
- You have been in a tanning booth or have had strong sun exposure the same day as your service is scheduled.
- You have a current outbreak on the area you are receiving waxing services (ex. herpes simplex) you will need to wait 2-3 weeks until all lesions have healed.
- If you have received laser resurfacing services within the past 4-6 weeks.
- If you have had a chemical peel, I recommend waiting 2-3 weeks until your next waxing service.
- If you are taking any Acne medication, I ask that you discontinue using for one week prior to waxing and after your service. As for Accutane, you must be off of one year before waxing again.
YES, I will still wax you if:
- You are on your period. I just please ask that you wear a tampon prior to arriving to your service.
- You are pregnant/and or breastfeeding.
Just know, you will be more sensitive due to hormones!
I consent to photos/videos of my services taken by WAXBYKAYLA LLC. These photos/videos may be used on social media platforms to promote my business. I hereby grant WAXBYKAYLA LLC permission to use my likeness in a photograph, video, or other digital media (“photo”) in any and all of its publications, including web-based publications, without payment or other consideration. By entering my name in the form below, I understand and agree that all photos will become the property of the WAXBYKAYLALLC and will not be returned.*

YesNo
Consultation Date & Time
Signature*

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Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my Esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the Esthetician immediately. 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 had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the Esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
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Waxing Consent & Intake Form

WAXBYKAYLA LLC

Precautions & Considerations