Waxing Consent / Client Intake Form printable pdf download

Therapist: ____________________

Time: ____________________

WAXING CONSENT & CLIENT INTAKE FORM

Name: ___________________________________________ Phone: (_______) ____________________

D.O.B: ____/____/____ Street Address: ___________________________________________________

City: _________________ State: _______ Zip: __________ Email: ______________________________

Emergency contact: __________________________________ Phone: (_______) ____________________

Occupation: __________________________ How did you hear about us? ___________________________

What body part(s) are we waxing today? __________________________________________________________

When did you last shave? _______________________ When is your menstrual cycle’s start date? _________________

***Because of water retention and for your personal comfort, avoid

hair removal two days before your cycle starts and two days after.

Do you have or prone to any of the following: (please mark all that apply)

____Ingrown Hairs

____Scarring

____Bumps

____ Hyperpigmentation

____Bruising

____ Allergies

***If yes, please list: __________________

Are you diabetic? ___ Yes ___ No

Have you ever been treated for cancer? ___ Yes ___ No

Have you used any of the following in the last 48-72 hours? (please mark all that apply)

____Accutane

____Glycolic Acid

____Scrub or Peel

____ Retin-A

____Resorcinol

____ Alpha-Hydroxy Acid

Have you used other skin thinning medications? ___ Yes ___ No

If yes, please list: __________________

Do you use a tanning bed? ___ Yes ___ No

Any other illness/condition a medical professional is presently treating you for? ________________________________

*New use of any of the medications listed above increases the possibility of a reaction. Please inform

the esthetician if you have begun taking any new medications since your last session.

*Please note waxing does have certain side effects such as skin removal, redness, scabbing, bruising,

scaring, swelling, tenderness, hyperpigmentation, and/or pimples.

*Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. The most

common occurrence of this is in a Brazilian bikini wax.

I have read the above information and if I had any concerns, I have addressed them with my esthetician. I give

permission to my therapist to perform the waxing procedure we have discussed and will hold her harmless from any

liability that may result from this treatment. I have given an accurate account of the questions asked above including

Waxing Consent / Client Intake Form