ME BEAUTY REPUBLIC WAXING & SKINCARE
Full Name:
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone:
*
Format: (000) 000-0000.
Email:
*
example@example.com
How did you find out about ME Beauty Republic?
Google/Bing (search engine)
Social Media (Instagram, Facebook)
Existing Client Referral
Other
WAXING HISTORY
How often do you wax?
*
First time
Occasionally
Monthly
Other
Have you ever had a reaction to waxing?
*
No
Yes
If yes, explain:
HEALTH & MEDICATION INFORMATION
Have you been under the care of a physician, dermatologist, or other medical professional within the past year?
*
No
Yes
Details:
Are you currently taking any medications? If yes, list them.
*
No
Yes
Details:
Do you have any allergies? If yes, list them.
*
No
Yes
Details:
Do you have any health conditions, past or present, that may be relevant to your waxing service? If yes, explain.
*
No
Yes
Details:
Are you pregnant?
*
No
Yes
Details:
Do you currently have a sexually transmitted infection that may affect the area being waxed?
*
No
Yes
Details:
Have you been exposed to the sun or used a tanning bed within the last 48 hours?
*
No
Yes
Details:
Are you using Retin-A, Accutane/isotretinoin, alpha hydroxy acids, tetracycline, acne medications, or other skin products that may affect skin sensitivity? If yes, list them.
*
No
Yes
Details:
Have you recently received Botox, dermabrasion, chemical peels, laser treatments, or other skin treatments? If yes, when?
*
No
Yes
Details:
Do you have diabetes, phlebitis, eczema, psoriasis, or another condition affecting the skin or healing? If yes, explain.
*
No
Yes
Details:
Is there anything else I need to know to better serve you?
WAXING CONSENT & ACKNOWLEDGMENT
I understand that waxing removes hair from the follicle and may temporarily cause redness, tenderness, irritation, swelling, sensitivity, bruising, skin lifting, breakouts, ingrown hairs, or other reactions. I understand that individual skin responses vary and results cannot be guaranteed.
I have disclosed medications, allergies, health conditions, recent skin treatments, sun/tanning exposure, and other information that may affect the safety of my waxing service. I agree to inform the esthetician of any changes before future services.
I understand that waxing may be declined, modified, or stopped if the esthetician determines that the skin or treatment area should not be waxed. I agree to follow the pre-care and aftercare instructions provided.
I understand the nature of the waxing service I am receiving and voluntarily consent to the service. I acknowledge that I have had the opportunity to ask questions before treatment.
Client Signature:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: