Wax Client Intake Form
New Facial client information
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Email *
Name *
Date *
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Address *
Cell Phone (we text appointment reminders) *
Can we use your email for newsletter and promotions?
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Birthday (we send birthday coupons) *
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How did you hear about us? *
Is this your first wax? *
If No, When was your last wax/shave? *
What area(s) is the hair removal being performed? *
Required
Are you currently under a physician's care for a skin condition? *
Are you currently or in the past 12 months taken Accutane or other oral Acne medication? *
Are you currently or in the past 3 months taken Retin-A, Retinol, or other powerful Hydroxy Acids? *
Have you had a chemical peel within the last 6 months? *
Have you had an IPL/Laser Facial within the last 3 months? *
Are you exposed to extended periods in the sun or are you planning a vacation with extended periods in the sun in the near future? *
Are currently under any medication? (Please list) *
Do you have or have you previously been treated for skin cancer? (what type) *
Please check if you are affected by any of the following: *
Required
Do you have any allergies to cosmetics, food, or drugs? *
Female Clients: When is your next menstrual cycle due to begin? (Always allow 5 days for your menstrual cycle due to water retention, higher likeliness of bruising may occur and for your own personal comfort. You should allow 2 days before and 2 days after your cycle is completed.) *
Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and if I have any concerns, I will address these with my skin therapist, I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. *
Required
Post Treatment Care: Gently was area with a mild cleanser within the first 24 hours of treatment. To help prevent ingrown hairs exfoliate area 2 to  3 days after treatment. Use to a light moisturizer to keep skin soft and supple. If case of irritation a topical antibiotic can be applied to area or calendula ointment. If irritation persist please consult a doctor.
I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately. *
Required
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold esthetician, nor Glow Organic Wellness Spa, responsible for any of my conditions that were present, but not disclosed at the time of the skincare procedure, which may be affected by the treatment performed today. *
Required
Signature of Client (type your name) *
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