Client Consent Form
Waxing Intake form
Full Name
First Name
Last Name
Todays date
-
Month
-
Day
Year
Date
Date of birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How did you hear about me?
Please Select
Friend Referral
Instagram
Tik Tok
Word of Mouth
Other
Have you been waxed before?
No, I have never been waxed before
Yes, 1 month ago
Yes, over a Year ago
Yes, more than a month ago
If you are currently using any of the following medications,you cannot be waxed today: * Accutane, Renova, Tretinoin, Adapalene, Allistra, Avage, Isotretonoin, Anita, Differin, Retin-A, Tazarotene *
Do you have any known medical Conditions?
Do you have any known Allergies?
Are you using Accutane, Retin-A, Renova, or any oral form of Retin-A?
Yes
No
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
Yes
No
Have you been exposed to tanning bed/sun within the past 8hrs OR plan to?
Yes
No
Are you diabetic?
Yes
No
Are you okay with before/ after photos or videos to use for online portfolio?
Yes
No
Are you currently pregnant?
**FOR MALE CLIENTS***
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By signing below you have agreed to the following :
I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed and understand the contradictions to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable.
Clients Signature
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