WAXING INTAKE FORM

WAXING INTAKE FORM

MADD GLOW BEAUTY
TODAY'S DATE

MonthDayYear
Date
NAME

First NameLast Name
BIRTHDAY

MonthDayYear
Date
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE
Format: (000) 000-0000.
EMAIL
example@example.com
Have you been waxed before?
Do you have any tendencies towards:
Ingrown hair
Hyperpigmentation
Eczema
Breakouts
Bruising
Psoriasis
Scarring
Are you currently using or taking:
Isotretinoin/Accutane
Retin-A
Indoor Tanning
Any Scrubs. Peels or Retinols
Fillers/Injections
Location
When?
Topical or internal medications
Please list
Herpes Virus
Frequency:
Staph/MRSA
Frequency:
Allergies
Please list:
Other information:
Waxing may cause: Bruises, scabs, scarring, redness, hyperpigmentation, pimples or a flare up of any of the above mentioned conditions/responses. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. (Most common occurrence is in Brazilian Bikini waxes, male or female.)
I understand that if I have Herpes or Staph/MRSA, I may experience an outbreak after the waxing service. The professional has explained the best way to minimize or prevent an outbreak when waxing regularly.
I understand I may carry Herpes and/or Staph/MRSA without any physical symptoms or a medical diagnosis. I also understand that the waxing service does not allow the opportunity to contract these conditions from my technician.
I understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications I must inform the professional PRIOR to any service in the future.
I understand that I must be showered and prepared for my service.
I understand that if I cancel or miss my appointment within the 24 hour cancellation policy I will be charged HALF of the service fee.
Print Name

First NameLast Name
Print Name

First NameLast Name
Authorizing Signature
Should be Empty:

WAXING INTAKE FORM

Do you have any tendencies towards:

Are you currently using or taking: