Waxing Treatment Consultation Form

Name *

Date of birth*

Date

Address*

City*

State*

Zip*

Phone*

Email*

example@example.com

Emergency Contact*

Phone Number*

How did you hear about us*

Do you have or have you had any of the following conditions? Please select if yes.*

Have you used an Alpha Hydroxy Acid (AHA) or Glycolic products in the past 48-72 hours?*

YesNo

Are you using Retin-A, Renovate, or currently on Accutane (an oral form of Retin-A)?*

YesNo

Are you using any other skin thinning products and/or drugs?*

YesNo

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

YesNo

Are you Diabetic?*

YesNo

Do you use tanning beds?*

YesNo

Have you received Botox or filler within the past 2 weeks?*

YesNo

Have you undergone a skincare treatment (ex.Facial) within the last week?*

YesNo

Are you currently taking medications? If SO, please list all (including over the counter drugs/herbal supplements)*

What skin products do you regularly use on your skin?*

Have you ever been treated for cancer? If yes, when and what types of therapies were used?*

Please list any other illness/condition you are currently being treated for by a medical professional

When is your next menstrual cycle due to begin?*

Have you had this treatment before?*

Have you had a reaction to this treatment Explain*

I understand that waxing may result in temporary redness, irritation, or sensitivity.

I acknowledge that waxing can cause skin lifting or bruising, especially if I am using certain medications or have sensitive skin.

I confirm that I have disclosed any medical conditions, allergies, or skin sensitivities that may affect my waxing treatment.

I understand that for best results, hair should be at least 1/4 inch long.

I have been advised to avoid sun exposure, exfoliation, hot tubs, saunas, and certain skincare products (e.g., retinol, acids) for 24-48 hours after waxing.

I acknowledge that I should not receive waxing services if I have had recent sunburn, open wounds, or skin infections in the treatment area.

I understand that Luxebrow Bar and its estheticians are not responsible for any adverse reactions due to undisclosed conditions or failure to follow aftercare instructions.

By signing below, I acknowledge that I have read, understood, and agree to the terms of this waxing service.

Client Name printed*

Client Name signature*

Date*

Date

Parent/Guardian Full Name.*

Parent/Guardian Phone Number*

I, the parent or legal guardian of the minor named above, consent to the waxing services provided. I understand the nature of the treatment and acknowledge that any questions have been answered to my satisfaction.

Signature*

Date*

Date

Waxing Treatment

Parent/Guardian Consent for Minor