Waxing Intake Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) Occupation Emergency Contact(Required) Emergency Contact Phone(Required)Emergency Contact Relationship HistoryWhen was your last wax? Date of last facial hair removal Method of Removal Chemical Removal Laser Shaving Waxing Threading Other What body part(s) would you like waxed today? List all prescription drugs, shots, or creams you are currently using FEMALE GUESTS: When was your last mensural cycle start date? Do you have or are you prone to? Ingrown Hairs Scarring Bumps Hyperpigmentation Bruising Do you use any of the following? Accutane Retin-A Alpha-hydroxy Acid Glycolic Acid Resorcinol Scrub or Peel Tanning beds Have you been diagnosed with cancer in the last 5 years? Yes No If yes, when: Do you have diabetes or any other skin compromising condition? Yes No List any other illness/condition you are presently experiencing or being seen by a doctor for:Are you using any skin thinning products or drugs? Yes No If yes, specify Have you used any Retinol/Retin-A/Tretinoin/Accutane/AHA’s on the area to be waxed in the past week? Yes No New use of any of the medications listed above increases the possibility of a reaction. Please inform the Esthetician if you have begun taking any new medications since your last session.BODY/FACIAL WAXING DISCLOSURE(Required)Please check each box to acknowledge. I understand that the use of any medications increases the possibility of a reaction. I understand that waxing can have certain side effects such as skin lifting/removal, redness, scabbing, bruising, scarring, swelling, tenderness, hyperpigmentation, and/or breakouts. I understand that waxing soft tissue may cause the skin to tear resulting in the need for stitches. The most common occurrence of this is in a Brazilian bikini wax. I will arrive showered, with hair trimmed 1/4 to 1/2 inch (trimming is an additional charge). I have not shaved for three weeks before my wax appointment. I will refrain from tanning 48 hours before and after my appointment to reduce the risk of hyperpigmentation. Consent(Required) I agree to the notice.I have read the above information and I have addressed any concerns with my Esthetician. I give permission to my practitioner to perform the waxing procedure we have discussed and will hold them 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. I have read and understand the post-treatment home care instructions. I am willing to follow the recommendations made by my Esthetician for a home care regimen that can minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. 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 LaVida Massage or the Esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.Signature(Required)Untitled First Choice Second Choice Third Choice EmailThis field is for validation purposes and should be left unchanged.
