Waxing Consent Form
Please complete this waxing consent form based on the provided PDF. All fields are optional unless the PDF clearly requires otherwise.
Client Information
Name
Address
City
State
Zip
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Health and Exposure Screening
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
Yes
No
Are you using Retin-a, Renova or Accutane?
Yes
No
Are you using any other skin thinning products and/or drugs?
Yes
No
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
Yes
No
Do you use a tanning bed?
Yes
No
Are you diabetic?
Yes
No
Are you currently taking medications? If so, please list all (including over-the-counter drugs and herbal supplements).
What skin products do you regularly use on your skin?
Have you ever been treated for cancer? If yes, when and what types of therapies were used?
Please list any other illness or condition you are currently being treated for by a medical professional.
Consent and Signatures
(Female clients) When is your next menstrual cycle due to begin?
Client Name (printed)
*
Client Signature
*
Client Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Esthetician Name
*
Esthetician Signature Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: