Bare Necessities Wax Studio

Name

First NameLast Name

Phone Number

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

Date of Birth

Date

Email

example@example.com

Emergency Point of Contact Name

First NameLast Name

Emergency Point of Contact Phone Number

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

How did you hear about us:__________________________________________________.

Have you had waxing treatments previously?

Have you ever had any adverse reactions?

If yes, please describe: _____________________________________________________________________________________________

I am pregnant and have received my doctor's permission for waxing

🚫 Contraindications – When Services Cannot Be Performed

For your safety and to protect the integrity of your skin, waxing services may not be performed under the following conditions:

Waxing cannot be performed if you:

• Are currently using or have recently used Isotretinoin (Accutane) within the past 6–12 months, depending on skin condition

• Are using prescription retinoids (Retin-A, Tretinoin, Differin) on the area within the past 7 days

• Have taken medications that significantly affect skin integrity, unless cleared by a physician

Waxing cannot be performed on areas with:

• Open wounds, cuts, abrasions, or active infections

• Sunburned, irritated, or inflamed skin

• Active herpes outbreaks (cold sores or genital lesions)

• Active rashes, dermatitis, eczema, or psoriasis flare-ups

• Thin, fragile, or compromised skin

Waxing may be postponed if you:

• Have recently had chemical peels, laser treatments, or resurfacing procedures (within 1–2 weeks or as advised)

• Are currently undergoing medical treatments (such as chemotherapy or radiation) without physician clearance

✨ Important Note

Services may be modified, postponed, or declined at the discretion of the technician based on a visual skin assessment at the time of your appointment.

I understand that certain conditions may prevent me from receiving waxing services and that services may be refused for safety reasons

🩺 Medical Conditions (Checkbox – Required)Please select any conditions that apply to you:

If other specifiy:__________________________________________________________________________________________________________.

⚠️ Additional Medical Information (If applicable)

If you selected “Diabetes”:

Do you consider your diabetes well controlled?

Do you typically heal well without complications?

🩺 Allergies: Do you have any known allergies?

If yes, please specify:blanks

🩺 Medical Acknowledgment

I understand that certain medical conditions, including but not limited to diabetes, poor circulation, and autoimmune disorders, may increase the risk of skin sensitivity, irritation, or delayed healing following waxing services.

I confirm that I have disclosed all relevant medical conditions to my technician.

🩺 Physician Clearance (When Recommended)

I understand that for certain medical conditions, including diabetes, pregnancy, or skin-related concerns, physician approval may be recommended prior to receiving waxing services.

I acknowledge that I may be advised to obtain medical clearance before certain services

RISKS AND SIDE EFFECTS:

I have been informed and understand that waxing may have side effects, which can include but are not limited to:

Redness, swelling, and temporary irritation of the skin.
Bumps, pimples, or minor breakouts.
Ingrown hairs.
Bruising or skin lifting.
Hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin).

POST CARE INSTRUCTIONS:

The area of the skin that will be waxed may or may not be sensitive for 24-48 hours after waxing.
Avoid any low pH products on that area such as Retin-A, Glycolic/Salicylic Acids, topical acne
preparations such as benzyl peroxide, and the like for up to 48 hours. Avoid exercise for 24 hours
as perspiration can cause prolonged redness and irritation and may cause stinging. Avoid direct
sun exposure to the treated area(s) and be sure to wear sunscreen as always but particularly on the
treated area when in the sun.

Client Agreement, Consent & Release of Liability

Please read the following statements carefully. Your signature confirms your understanding and agreement.

1. Voluntary Consent & Acknowledgment of Risks:

I have voluntarily chosen to receive waxing services from Bare Necessities Wax Studio. I have been informed of, and I understand and accept, the potential risks and side effects associated with waxing, which include but are not limited to: temporary redness, swelling, bruising, skin sensitivity, bumps, pimples, ingrown hairs, skin lifting, and changes in skin pigmentation.

2. Client's Duty of Full and Honest Disclosure:

I confirm that I have read and truthfully answered all questions on this intake form. I understand that my wax technician is not a medical professional and relies entirely on the information I provide to ensure the safety of my service. I agree that it is my sole responsibility to disclose any and all health conditions, allergies, and medications (topical or oral), both now and in the future.

3. Ongoing Responsibility to Update:

I agree to inform my wax technician of any changes to my health, medications, or skincare routine (especially the use of retinoids or exfoliants) before each future appointment. I understand that my circumstances can change and that what is safe today may not be safe in the future.

4. Agreement to Follow Instructions:

I agree to follow the pre- and post-waxing care instructions provided to me by my wax technician to minimize the risk of adverse reactions. I understand that my results and skin health depend on my adherence to these instructions.

5. Release of Liability:

In consideration for receiving this service, I hereby release and hold harmless Bare Necessities Wax Studio and its wax technician(s) from any and all liability, claims, demands, or actions for any injury, damage, or adverse reaction that may occur as a result of the service, especially those that arise from my failure to fully disclose any and all of my health conditions, medications, or allergies, or my failure to follow the provided instructions.

By signing below, I certify that I have read and fully understand all the terms of this agreement and consent form. I confirm that I am over 18 years of age (or have a parent/guardian signature below).

Signature

Date