Client Information

Full Name: *

Date of Birth: *

Phone Number: *

Email Address: *

Emergency Contact Name & Phone: *

Medical History

Please check Yes or No for each of the following:

Eye infections or diseases (e.g., conjunctivitis, styes)

Yes

No

Eye surgery or laser vision correction

Yes

No

Glaucoma or cataracts

Yes

No

Dry eye or excessive tearing

Yes

No

Blepharitis (eyelid inflammation)

Yes

No

Allergies to adhesives, latex, or cosmetics

Yes

No

Sensitive skin or eyes

Yes

No

Use of contact lenses

Yes

No

Recent cosmetic procedures (facials, peels, etc.)

Yes

No

If you answered "Yes" to any of the above, please explain:

Current Medications

Include any eye drops or topical treatments:

Consent & Release

Consent & Release *

- I understand that waxing removes hair from the root and may result in minor skin irritation, redness, sensitivity, or bumps.

- I have disclosed all medical conditions, allergies, and medications that may affect my waxing experience

- I understand that waxing over moles, warts, or inflamed skin is not recommended and I will inform the technician of any such areas.

- I understand that it is my responsibility to follow all aftercare instructions provided to me following the service.

- I release the salon, technician, and affiliated personnel from any liability arising from adverse reactions or complications related to the waxing treatment.

I understand that I need to let the clininc know 24 hours prior to an appointment, rescheduling or cancelling my appointment

Client Signature: *

Clear

Client Name: *

Date: *

I agree to terms & conditions provided by the company.

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