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Form
BARE HAVEN WAX STUDIO CONSENT/CLIENT INTAKE FORM
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Are you 18 years or older?
*
Yes
No
Are you currently using any of the following?
Accutane (last 6 months)
Retin-A or any other topical acne medication (within 7 days)
Antibiotics
Scrub, Facial, or Peel (3 days)
Tanning Bed (24 hours)
Glycolic Acid
Alpha or Beta-hydroxy Acid (2 days)
Are you taking anything else that is not listed above that could interact with your waxing service?
Do you have any of the following skin conditions?
Please Select
Sensitive skin
Eczema
Psoriasis
Active acne in treatment area
Other
None
Any Allergies?
Yes
No
"If yes, please list your allergies"
SERVICE CONSENT
I understand that the services I am receiving (including waxing, facials, or body treatments) may cause temporary side effects such as skin removal, redness, sensitivity, scabbing. bruising, scarring, swelling, tenderness, pimples, tenderness, in-grown hairs, or irritation. I acknowledge that results may vary. I give permission to my wax specialist to perform services related to waxing or facial services and I assume any risk, and, except as otherwise prohibited by law, take full responsiblity and waive any claims associated with Bare Haven Wax Studio and events performed by its licensed specialist. This is a waiver of any claim or action against Bare Haven Wax Studio and the wax specialist.
Signature
LIABILITY WAIVER
I voluntarily consent to services performed at Bare Haven Wax Studio. I release the esthetician and business from any liability related to reactions or complications that may occur.
*
I agree
PHOTO RELEASE
I give permission for photos/videos taken during service to be used for marketing, social media, and educational purposes.
Yes
No
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
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