Date

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Email address *

example@example.com

Have you used ANY hair removal methods (shaving, waxing, Nair) in the past 2 weeks?

Yes No

Have you used any Alpha Hydroxy Acids (Glycolic, Lactic)?

Yes No

Are you using any other skin thinning products and/or drugs?

Yes No

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

Yes No

Do you use a tanning bed?

Yes No

Are you a diabetic?

Yes No

Are you taking any of the following medications? Check all that apply

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 treatment for by a medical professional

FEMALE CLIENTS: Are you currently on cycle (PLEASE WEAR CLEAN TAMPON FOR WAXING)

Yes No

Would you be interested in subscribing to our VIP email and/or text list (to stay informed of sales and specials)?

Email list only Text list only Both email and text list I would NOT like to be subscribed to the email or text list

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Waxing Consent Form