Facial Waxing Consent Form
Complete your client details, treatment history, and consent preferences for today’s visit.
Client Information
Full Name
*
First Name
Last Name
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
New or Returning Client
*
New Client
Returning Client
Has anything changed since your last visit?
*
Yes
No
Please describe what has changed since your last visit.
*
Body Areas to Be Treated During This Wax Session (Select all that apply)
*
Eyebrows
Lip
Chin
Cheeks
Nose
Ears
Full Face
Underarms
Half Legs
Other (please specify)
Facial Waxing Contraindications
Facial Procedures in the Past 30 Days (Select all that apply)
*
Facial waxing
Facial peel
Laser/IPL
Dermaplaning
Microdermabrasion
Botox or fillers around the treatment area
None
Other (please specify)
Are you pregnant or breastfeeding?
*
Yes
No
Retinoid use in the treatment area within the past 7 days (Retin-A, tretinoin, adapalene (Differin), or tazarotene)
*
Yes
No
Accutane use within the past 12 months
*
Yes
No
Recent chemical peel or laser/IPL on the treatment area
*
Yes
No
Are you currently taking any medications or using topical products that may increase skin sensitivity or affect waxing (such as blood thinners, corticosteroids, antibiotics, retinoids, or prescription acne medications)?
*
Yes
No
Please list the medication(s) or product(s).
*
Do you have any open cuts, sunburn, rash, or active skin infection in the treatment area?
*
Yes
No
Have you ever had a previous allergic reaction to wax or waxing products?
*
Yes
No
Photo Consent
*
Yes, I consent
No, I do not consent
Waxing Risks, Contraindications & Aftercare Acknowledgment
I certify that the information I have provided is true and complete to the best of my knowledge. I have read and understand the information in this consent form, have had the opportunity to ask questions, understand the potential risks and benefits of the requested service, and voluntarily consent to receive treatment from Phases Esthetics. I understand that I may withdraw my consent at any time before treatment begins.
*
I agree
Full Legal Name (Electronic Signature)
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: