Waxing Consultation Form
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Pronouns
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
How did you hear about us?
How did you hear about us?
*
Social Media
Online Search
Referral
Other
If referral, please list name:
Who do you want to book with?
*
Please Select
Halley
Whitnie
Not Sure
What waxing services are you wanting to book?
Brow
Brows with Lip AND Chin
Brows with Lip OR chin
Cheeks
Chin
Ears
Face
Lip
Lip and Chin
Neck
Nostril
Unibrow Only
Abdomen
Full Arm
Half Arm
Full Back with Shoulders
Bikini Standard
Bikini Standard Thong
Brazilian 4 week maintenance
Brazilian 6 weeks or more
Chest with Abdomen
Fingers
Glutes
Full Leg
Half Leg
Full Leg w/ Bikini Line
Toes
Under Arm
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
Have you used Retin-A, Renova, or Accutane within the past year?
*
Yes
No
Are you using any other skin thinning products and/or drugs that thin the blood?
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
Yes
No
Are you currently taking any medications that can cause skin thinning or irritation? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any skin illness/conditions which you are currently being treated for by a medical professional.
Do you have any open skin lesions?
Yes
No
Do you have any allergies? If so, please list.
Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
*
I agree
I understand that chemicals and wax can damage my jewelry, clothes and/or accessories and I will dress accordingly for my appointment. I understand that the salon and the waxing technician is not liable for any accidental damages.
*
I agree
I understand, have read and completed this questionnaire truthfully. I understand that previous treatments and/or chemical services can affect the outcome of my desired results. I have fully disclosed all requested information related to my skin history. I understand that withholding information or providing misinformation may result in contradictions and/or irritation to the skin service being received.
*
I agree
I understand that if I cancel my appointment within less than 24 hours I will be charged 75% of the service fee. If I no show my appointment, I will be charged 100% of the service fee. Repeated late cancellations will result in a deposit being required to book for all future appointments.
*
I agree
Signature
*
Date?
*
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