Wax Questionnaire

Wax Questionnaire/ Informed Consent

Today’s Date _________________________ Birthday__________________________

Name___________________________________________________________

Address_________________________________________________________

City__________________________________________State___________Zip______________

Cell Phone( )_________________________________________

Email__________________________________________________________

What is your occupation? ________________________________________________________________

How did you hear about us? ________________________________________________________________

What body part are we waxing today? _________________When did you last shave? _____________

How often do you shave___________________?

Do you have any tendencies to:

Ingrown hair _____yes _____no Hyperpigmentation _____yes _____no

Scarring _____yes _____no Bruising _____yes _____no

Bumps _____yes _____no

Are you currently using or taking:

Accutane _____yes _____no Resorcinol _____yes _____no

Retin-A _____yes _____no Glycolic Acid _____yes _____no

Alpha-hydroxy Acid _____yes _____no Scrub or Peel of any kind _____yes_____no

Medical Data

Herpes Virus_____yes _____no MRSA_____yes _____no

Allergies _____yes _____no Please list_____________________________________________

Other___________________________________________________________

If I have Herpes or MRSA I may experience an outbreak. My professional has explained the reasons and I understand. __________please initial.

I understand I may carry Herpes and/or MRSA without any physical symptoms or having had a medical diagnosis confirmed___________ please initial.

Waxing may cause: Bruises, scabs, scarring, redness, hyperpigmentation or pimples.

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 have been honest about my health conditions. I also understand that any false information could result in of the above mentioned reactions. If such reactions occur, I can not hold Della Bella Minerals & Aesthetics/Elizabeth Pasko responsible. If I change my skin care routine or medications I must inform the Elizabeth Pasko PRIOR to starting any service in the future.

_______________________________________________________________________________________

Aesthetician Signature Date Client Signature Date

One last note about waxing:

We prefer not to tweeze your hair. This takes some getting used to on your part, but the reason for this is

that it will make your waxing service longer lasting.

Perfect waxing means wax is applied and removed and all the hair comes off. Now you have a smooth,stubble free area that remains hairless in-between appointments. This only occurs if the hair is longenough to be pulled out by the root. Tweezing interrupts this from happening.

So we ask that you be patient for about 1 month, don’t tweeze, shave or use a depilatory cream, come in every 3 to 4 weeks like clockwork and you will love your waxing even more then you do now!

Client Recap

I declare that my skin care routine, medications, or health conditions have not changed from the statements of the previous page and are exactly the same as when I originally signed the release form.

Client Signature Date

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