Waxing Intake & Consent Form

Waxing Intake & Consent Form
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
Emergency Contact Name + Phone
Are you taking any medications?

YesNo
If yes, please explain.
Do you have any allergies

YesNo
If yes, please list
Do you have any of the following?

DiabetesSkin thinning meds (e.g. Accutane)Autoimmune disorderCold sores/herpesEczema/PsoriasisNone of the above
Have you ever had waxing services before?

YesNo
Have you experienced an adverse reaction to waxing? (Yes/No) if yes, please explain.
Pre/Post Wax Guidelines
I understand that waxing may cause redness, irritation, and ingrown hairs. I agree not to wax over sunburned, broken, or recently exfoliated skin and will follow all aftercare instructions.
I have read and understand the waxing guidelines above.*

I understand
Consent to Waxing Service
I consent to receive waxing services from Modest Charm Beauty Lounge. I release the service provider from any liability resulting from disclosed or undisclosed conditions.
I consent to waxing and confirm all info is true to the best of my knowledge.*

I consent to waxing and confirm all info is true to the best of my knowledge.
Areas to be waxed

UnderarmsFull ArmsFull LegsBikiniBrazilianChin/LipSideburnsBackOther
Other
Signature

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Date

MonthDayYear
Date
Should be Empty:

Pre/Post Wax Guidelines