WAX Intake Form WAX Intake Form For All Wax Services Including Brow Waxing — Confidential Client RecordCLIENT INFORMATIONToday's Date:(Required) MM slash DD slash YYYY Birthday:(Required) MM slash DD slash YYYY Appointment Reminder Preference (select one):(Required) Call Text Email HOW DID YOU HEAR ABOUT US?(Select One): Ad Internet Referral Referral Name:SERVICE INFORMATIONDesign / Style Requested:Have you been waxed before? Yes No When?What body part are we waxing today?When did you last shave or trim?SKIN TENDENCIESDo you have any tendencies towards the following?Ingrown Hairs Yes No Breakouts Yes No Bumps Yes No Hyperpigmentation Yes No Bruising Yes No Scarring Yes No Eczema Yes No Psoriasis Yes No CURRENT MEDICATIONS & CONDITIONSAre you currently using or taking any of the following?Isotretinoin / Accutane Yes No Scrubs, Peels or Retinols Yes No Retin-A Yes No Self Tanners Yes No Indoor Tanning Yes No Fillers / Injections Yes No Location:Topical or Internal Medications: Yes No Please List:Herpes Virus: Yes No Frequency of Outbreaks:Staph / MRSA: Yes No Frequency of Outbreaks:Allergies: Yes No Please List:Other Information:Waxing may cause: bruises, scabs, scarring, redness, hyperpigmentation, pimples, or a flare-up of any of the above-mentioned conditions/responses. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. (Most common occurrence is in Brazilian Bikini waxes, male or female.) I understand that if I have Herpes or Staph/MRSA, I may experience an outbreak after the waxing service. The professional has explained the best way to minimize or prevent an outbreak when waxing regularly. I understand I may carry Herpes and/or Staph/MRSA without any physical symptoms or a medical diagnosis. I also understand that the waxing service does not allow the opportunity to contract these conditions from my technician. I understand all of the above-mentioned reactions. I also understand that if I change my skin care routine or medications, I must inform the professional PRIOR to any service in the future. I understand that I must be showered and prepared for my service. I understand that if I cancel or miss my appointment within the 24-hour cancellation policy, I will be charged $25.00 or HALF of the service fee, whichever is greater.SIGNATURESClient Print Name:(Required)Authorizing Signature:(Required)Date(Required) MM slash DD slash YYYY Technician Print Name:(Required)Technician Signature:(Required)Date(Required) MM slash DD slash YYYY You can copy and paste this directly into Google Docs, Microsoft Word, or any word processor. Once pasted, you can adjust fonts, spacing, and sizing as needed before saving or printing. Would you like any changes made?
