Waxing Intake Form Name * First Name Last Name Who referred you? First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Date of Birth * MM DD YYYY Are you currently or have you been on any of the following products in the past 4-6 weeks? Accutane Retinol Tretinoin Cream Alpha Hydroxy Acid Steroids Benzoyl Peroxide Cortisone Glycolic Acid Any peeling agents Hydroquinone Check any of the follow that apply: Diabetic Taking birth control Experienced a sunburn in the area to be waxed in the past week Currently on menstrual cycle Skin diseases Hepatitis Have you or anyone you have come in contact with in the past 10 ten days been exposed or had Covid 19? * Yes No Digital Signature * You may experience temporary redness and or swelling in the area waxed. This will subside within a few hours post waxing. If this does not subside you will need to contact this office and or your physician. You may also experience some breakouts (acne) in the area waxed, due to de-capping the hair follicle in that area. If you are taking the birth control pill and still agree on the waxing services, you may experience a discoloration in the area waxed. This is called hyperpigmentation which may not subside and may become permanent. After washing avoid deodorants, soaps, abrasive products, sunbathing and tanning salons for twenty to forty eight hours as it can cause irritation and hyperpigmentation. I have read and understand the statements above. I do not hold the Aesthetician or the facility responsible for any of the above mentioned statements. By signing this agreement I choose to go ahead with the service. First Name Last Name Thank you!
