Client Information

Full Name

Date of birth

Phone Number *

Email Address: *

Address:

City

State

Postal code

Occupation:

Emergency Contact Name :

Emergency Contact Phone Number:

How did you hear about us?

Is this your first waxing experience?

Yes

If no, where did you previously receive waxing services?

What type of waxing services are you receiving today?

Medical History

Please check Yes or No for each of the following:

Diabetes

Yes

Skin conditions (eczema, psoriasis, etc.)

Yes

Allergies (latex, fragrances, wax, etc.)

Yes

Use of Accutane or Retin-A in the past 6 months

Yes

Recent sunburn or tanning

Yes

History of keloid scarring

Yes

Recent chemical peels or microdermabrasion

Yes

Pregnant or nursing

Yes

Blood thinning medications

Yes

Hormonal imbalances or treatments

Yes

Autoimmune disorders (e.g., lupus, rheumatoid arthritis)

Yes

Cold sores or herpes simplex in the waxing area

Yes

Use of topical exfoliants (AHA, BHA, salicylic acid)

Yes

Botox or filler in the past 2 weeks

Yes

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

Skin Care Routine

Please describe your current skin care routine in the area to be waxed (cleansing, exfoliating, moisturizing, etc.):

Do you experience ingrown hairs?

Yes

Have you ever had an adverse reaction to waxing?

Yes

If yes, please describe:

Current Medications & Supplements

Please list any oral or topical medications you are currently taking, including over-the-counter, herbal, and vitamins:

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

Date

Technician Signature:

Clear

Date

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