Intimate Bleaching Intake Form
If you have any questions, concerns or need to reach out please text or email.
Full Name
First Name
Last Name
What skin concerns are you looking to correct such as ingrown hairs, dark spots, discoloration.
Is this your first time receiving a bleaching service?
Yes
No
If not, when was your last session?
Are you okay with 5 days of downtime, and flaking/peeling?
Yes
No
Have you shaved, used hair removal cream, or gotten laser hair removal in the past 7-14 days?
Yes
No
Do you have any skin conditions or sensitivities?
Are you taking any dermatologist prescribed medication topically or orally?
Are you pregnant or breastfeeding?
Pregnant
Breastfeeding
Neither
Are you undergoing any cancer treatment?
Yes
No
Do you have a shellfish allergy?
Yes
No
The treatments I received are voluntary and I release the company and/or skincare professional from liability.
Yes
No
I understand the area must be hairless. I am aware that a wax is not included but can be added on. I understand wax or laser are the best options for hair removal for intimate bleaching and shaving is not recommended as it will take more sessions.
Yes
No
I have read and completed this questionnaire truthfully. I understand that withholding information or proving misinformation may result in contradictions and/or irritation to the skin from the treatments received.
Yes
No
Additional comments or concerns
Signature
Date
-
Month
-
Day
Year
Date
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Should be Empty: