Wax Client Intake

Client Name

First NameLast Name

Birth Date

MonthDayYear

Please upload ID for proof of age

Gender

Other

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How did you hear about us?

Other

If someone referred you please leave there name

Please leave your Instagram handle

There is a cat on premises. Are you allergic to cats?

Do you have any known allergies or sensitivities to any of the following?

Please detail any specific allergies or skin reactions we should be aware of:

What service ares are you getting waxed?

When was the last time you shaved or waxed the area?

Have you been Waxed before?

If you checked yes, did you have any reaction or was there anything you would like me to know about your past experience?

Do you consent to the photography and video recording of your service, and to the use of these materials for promotional, educational, or social media purposes?

Would you like to add a rhinestone design applied after your Brazilian for a $5 fee? If yes, choose which design

Would you like to add on extractions for a $25 fee? This is good for anyone who experiences ingrown hairs, to help relieve any pain or irritation as well as the hair, and currently has them during the service.

Would you like to add on a Hydrogel Vagacial mask for a $25 fee? This is good for anyone who would like to sooth, cool, and reduce redness after there Brazilian wax.

Would you like to add on one of the mini after care kits for $20?

Would you like to add on the after care bundle (strawberry champagne exfoliant, and ingrown hair oil) for $40? Regularly $47

Please check any of the following that apply

If you checked yes or other to any of these please provide further information.

Are you currently using or have you used any of the following within the last 6 to 12 months?

If you checked any of the above, please list the specific product or medication name and how long ago it was last used:

Is there any other condition or significant information we need to know that may affect you during or after the procedure?

Please provide your further comments.

Emergency Contact Information: contact name, relationship, phone number

by agreeing below, I acknowledge that I understand and agree to the following terms: I am aware that the services provided are intended for cosmetic purposes only. I acknowledge that any potential risks or adverse effects, such as skin irritation, allergic reactions, or other complications, may occur during or after the service. I release Skinn By Haley LLC and its employees from any liability for injuries, damages, or claims arising from the services provided. I understand that it is my responsibility to disclose any medical conditions or allergies prior to receiving services.I voluntarily agree to these terms and take full responsibility for my decision to undergo the service or services.

Name

First NameLast Name

Signature

Date

Health & Medical History

Liability Statement