Waxing Questionnaire
My Earthly Essentials, LLC
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did You Hear of Us/Referral Name:
Best Way to Remind You of Your Appointment?
Call
Text
Email
Have You Been Waxed Before?
Yes
No
Do You Have a Tendency Towards (check all that apply):
Ingrown Hair
Bumps
Breakouts
Bruising
Scarring
Hyperpigmentation
Eczema
Psoriasis
Are You Currently Taking (check all that apply):
Isotretinoin/Accutane
Resorcinol
Retin-A
Glycolic Acid
Alpha-Hydroxy Acid
Scrubs or Peels
Indoor Tanning
Self Tanners
Do You Experience (check all that apply):
Herpes Virus
Staph/MRSA
Allergies
I understand waxing may cause bruises, scabs, scarring, redness, hyperpigmentation, pimples, a flare-up or reactions of any above-mentioned conditions and may cause skin tearing of soft tissue. Waxing may cause an outbreak of Herpes and/or Staph/MRSA in which I may be a carrier without any physical symptoms or medical diagnosis; waxing services do not allow the opportunity to contract these conditions from my technician. I will notify the professional of new skincare routines, products or medications prior to services in the future and agree to care of my skin post treatment in the manner suggested by the Esthetician. No specific results are guaranteed, and the waxing process has been fully explained with my questions/concerns addressed, if applicable.
Signature
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