Waxing Intake Client Consent Form

Please fill out this form for your body waxing procedure. This consultation form is to correctly evaluate your needs. All questions contained in this questionnaire are strictly confidential.

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Are you a New or Previous Returning Client?

Reffered by:

Within the last year, have you been under a dermatologist's care? (If Yes please specify)

Accutane Warning*** Using retinoids (Accutane or similar) can cause skin to rip off during the waxing process. For your own safety, we cannot wax you until you have been off of Accutane or similar medications for at least 6 month’s time. I understand the dangers of Accutane. Should I decide to take it in the future, I will inform my esthetician and will not get waxed at InkySPA at any time within 6 months of taking the medicine.

Which body part are you getting waxed & when was your last wax?

Have you shaved within 10 days of your appointment date? *(I understand some hairs may be missed if too short)

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

Yes

Sex

Female

Male

Do you use a tanning bed?

Yes

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):

What skin products do you regularly use on your skin?

Have you ever been treated for cancer? If yes, when and what types of therapies were used?

Please list any other illness/condition you are currently being treated for by a medical professional

Female clients -When is your next menstrual cycle due to begin? (Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after.)

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

Please check the box: I have read & agree to these terms

The paragraph below explains the liability waiver for InkySPA LLC. By signing your name below, you agree to hold InkySPA LLC and staff harmless from all liability associated with waxing, and skin care treatments.

I have completed this form to the best of my ability. I will consult with my esthetician regarding any medicine I am currently taking and any skin tendencies that may be problematic. I give permission to my esthetician to perform the waxing procedure, or skin care procedure and will hold her, her staff, and InkySPA LLC 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. 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 with the 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 liability waiver and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.

I agree to InkySPA LLC Terms & Conditions Click Here

www.inkyspa.com/tattoospapolicies

Todays Date

Month

Day

Year

Parent or Legal Guardian Signature Required (*Minors under the age of 18 must have parent signature)

Signature field is empty.