Waxing Consent Form
Please complete this form to provide your informed consent before your waxing service.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you had waxing before?
*
Yes
No
Have you ever had a reaction to a waxing service? If yes, please describe:
*
Do you have any tendencies to:
*
Ingrown Hair
Scarring
Bumps
Hyperpigmentation
Bruising
None of the above
Are you allergic to anything? If yes, please describe:
*
Have you received Botox treatments in the last 72 hours?
*
Yes
No
Are you using or taking :
*
Accutane or Tetracycline
Retinoids such as Retin-A, Renova, or Diferin
AHA/ Alpha-Hydroxy Acid
BHA/ Beta-Hydroxy Acid
Glycolic Acid
Any Other Medications
None of the above
Are you currently Pregnant?
*
Yes
No
Is your skin dry?
*
Yes
No
Signature
*
Date of Consent
*
-
Month
-
Day
Year
Date
Submit Consent
Submit Consent
Should be Empty: