Esthetic Client Intake Short

New Wax Intake Form
Full Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Date
How did you hear about Essential Esthetics by Zoey?*

GoogleFriend/Word of MouthFacebookInstagramSyringa Spa SuitesZoey
...General...
Everything affects your skin. Please answer so we can find what's right for you!
In the last year, have you*

Had surgeryBeen under a physician's care for anything other than annual wellnessI have not had surgery or been under a physician's care
If you answered yes to surgery or been under a physician's care in the last year, please explain below.
Do you have:*

PacemakerMultiple SclerosisEpilepsyDiabetesMetal ImplantsCold SoresNone
Please list all medications (including birth control options), vitamins, supplements, etc. *
Please type none if you are not on any medications.
Are you:*

PregnantLactatingTrying to become pregnantNone of the above
Please mark any allergies that you have:*

ApplesCitrusGrapesMilkFish/IodineCornAcrylicAdhesivesAspirinSulfurMetalEssential OilsNoneOther
...Skin Care...
Have you ever used or are currently using Accutane, Tretinoin Cream, Retinols (vitamin A), or Topical Antibiotics?*

YesNo
Please note I require 6 months from stopping Accutane before receiving waxing or facial services.
In the last 2 weeks, have you*

Been waxedUsed a tanning bedNone of the above
Please type in previous treatments you have received: (ie facials, chem peels, permanent makeup)
Please type none if you've never received a spa treatment.
What products do you use on a regular basis?*

Bar SoapMakeup Remover WipesCleanserExfoliantToner/MistMaskMoisturizerEye CreamSPFNoneOther
...Waxing...
What area(s) we are waxing today?*
Have you ever waxed that area before?*

YesNo
Do you experience:*

BumpsIngrown HairsAdverse ReactionsNoneNever Waxed
Favorite Music Artist/Genre (non-explicit)
...Consent...
I, the undersigned, being 18 years of age or older, consent to a waxing treatment in order to remove unwanted hair.

I have been informed that secondary effects may occur but not limited to:
1. Skin Removal
2. Redness, Swelling, and Tenderness
3. Hyper-pigmentation or Hypo-pigmentation
4. Allergic reaction to product ingredients
This treatment has been explained to me and I have been given satisfactory answers to my questions. I have addressed any concerns with my Esthetician. I understand post-treatment home care instructions. I am willing to follow recommendation made by my esthetician including but not limited to avoiding sun exposure and tanning, excessive heat (saunas and hot tubs), sweat, sex, exfoliation, and use of all active products on the area that has been waxed for the next 24 hours or more if I have been instructed. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read, fully understand and agree to the above treatment information and recommendations and hereby waive any claim for damages of any kind whatsoever against Essential Esthetics by Zoey and/or the esthetician.
I understand the secondary effects from waxing and agree to waive claim for damages.*

Yes
...Policies...
I have answered the above honestly and to the best of my knowledge. All of the above play a role in your chemical makeup, including your skin.

No guarantees can be made and no refunds will be given for services rendered. If, for any reason (including starting your cycle), you need to reschedule, cancel or adjust your appointment (ie, removing a service from what is scheduled or selecting a lower priced service), we kindly ask for 48 hours notice. All fees will use the card on file.

Less than 48 hours - 50% fee of scheduled service(s)
Same day up to 2 hours - 75% fee of schedule service(s)
Less than 2 hours or no call/no show - 100% fee of scheduled service(s)
Tardiness may result in modifying the service according to time remaining. Regular charges apply.

Repetitive cancellations/reschedules may prevent access to online booking.

I also understand that according to insurance and to maintain a peaceful environment, children and additional guests are not permitted under any circumstance.
I understand and agree to the policies stated above.*

Yes
Date
Signature*

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New Wax Intake Form

...General...

...Skin Care...

...Waxing...

...Consent...

...Policies...