Wax Client Intake Form There was an error trying to submit your form. Please try again. Wax Client Intake Form Full Name * This field is required. Phone Number * This field is required. Email * This field is required. Medical History Please check any of the following that apply to you: Bleeding disorders * Select an option Yes No This field is required. Cancer (If yes): Radiation in last three months? * Select an option Yes No This field is required. Cold sores / Fever blisters * Select an option Yes No This field is required. Herpes simplex * Select an option Yes No This field is required. Diabetes * Select an option Yes No This field is required. Eczema * Select an option Yes No This field is required. Psoriasis * Select an option Yes No This field is required. Hepatitis * Select an option Yes No This field is required. HIV / AIDS * Select an option Yes No This field is required. Keloids * Select an option Yes No This field is required. Rosacea * Select an option Yes No This field is required. Sunburns * Select an option Yes No This field is required. Varicose veins * Select an option Yes No This field is required. Open wounds or abrasions * Select an option Yes No This field is required. Currently using Retin-A, Retinol, Glycolic Acid, or Salicylic Acid * Select an option Yes No This field is required. Taken Accutane in the last 12 months * Select an option Yes No This field is required. Had recent chemical peels, laser, or skin treatments * Select an option Yes No This field is required. Known allergies (e.g., latex, wax products, fragrances) * Select an option Yes No This field is required. Comments Waxing Details Please check the area(s) to be waxed today: Upper Lip Full face Full arms Chin Eyebrow (clean up only) Half legs Jawline Underarms Full legs Sideburns Half arms Last time the area was shaved or waxed: This field is required. Client Acknowledgment & Consent I understand that waxing may cause temporary redness, swelling, skin irritation, minor bumps, or slight skin lifting. * This field is required. I confirm that I have disclosed all current medications, skin care products, and medical conditions that could affect my treatment. * This field is required. I agree to follow all post-waxing aftercare instructions provided by my esthetician (e.g., avoiding heat, sun exposure, heavy sweating, and tight clothing for 24 - 48 hours). * This field is required. I understand that if I fail to disclose the use of skin-thinning products or medications (such as Retin-A or Accutane), skin lifting or injury may occur, and I assume full responsibility. * This field is required. Submit There was an error trying to submit your form. Please try again.
