"Waxing Intake Form - Fusion Massage & Wellness"

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WAXING INTAKE FORM
Name _______________________________________ Phone (____) ______________ DOB ____________
*Cell phone provider _________________ (for text confirmations)
Address _______________________________________ City ______________ State ______ Zip ________
Email ____________________________________
Would you like to receive emails on monthly specials or discounts? Yes
No
How did you hear about us (family/friend’s name, internet search, etc.)? __________________________
Occupation ____________________________________________________ Male _______ Female _______
Emergency Contact ______________________________________ Phone (_____) _____________________
Have you used any of the following in the last 48 hours?
Check all the following that apply:
 Alpha Hydroxy Acid
 Glycolic Acid
 Treated for skin cancer?
 Diabetic
 Retin-A or Renova
 Accutane
 Allergic to latex
 Skin sensitivity
 Tanning bed
 Granular scrub/polish
 Any open wounds, sores, skin irritation? ______
 Benzoyl Peroxide
 Salicylic Acid
_________________________________________
 Using skin thinning products/drugs?
 Acne
 Dermatitis
 Eczema
 Seborrhea
 Psoriasis
 Herpes Simplex
Are you currently taking any medications?  Yes  No
*If yes, please list: __________________________________________________________________________________
Waxing for hair removal, particularly on the face carries risks. These risks may include redness, bruising and lifting of
the skin.
These conditions may be exacerbated by the use of certain pharmaceuticals and cosmetics, particularly those for anti-
aging and anti-acne treatments. Examples of these are retinoid, Retin-A, Renova, Accutane, and alpha hydroxyl acids
(AHA’s) like glycolic acid. Face waxing should be avoided when using these products.
Certain prescription medications may aggravate the skin when waxed, particularly those causing photo-sensitivity
(sensitive to sunlight). Examples of these are many antibiotics, such as tetracycline, and blood thinners such as Warfarin,
which may cause an individual to bruise easily.
Clients who are receiving aesthetic and dermatological peeling treatments may also experience redness and skin lifting
from waxing and therefore should avoid waxing while undergoing such treatments.
The use of tanning booths can also contraindicate waxing. Waxing should not be done 24 hours before or after tanning.
It should also not be done on an area that still shows an erythema (redness) from tanning.
Because the fields of pharmacology and dermatology are continually changing and expanding, there may be products
and drugs that cause negative reactions to waxing that have yet to be documented.
I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing
misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are
voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I further
understand that the work of the esthetician should not be confused as a substitute for medical examination, diagnosis, or treatment and
that nothing said in the course of the session should be construed as such. I agree to keep this institution informed as to any changes
in my medical profile. I also understand that by scheduling future appointments, I am liable for payment of said appointments if I fail to
cancel within the 24 hours stated in Fusion’s company policy. I understand and agree that I will be responsible for paying 100% of the
service fee for any no-showed or late cancelled appointments. I agree that Fusion will deduct this from my credit card, a gift card, or
series on file at their discretion if missed or cancelled appointment is not filled by another client. This policy is enforced in our desire to
be effective and fair to all clients and out of consideration for our therapist’s precious time as they do work on commission and as
Fusion does have a constant running waiting list. By signing this form, I agree to all terms listed on this form.
Signature ____________________________________________ Print Name _______________________________________________________ Date _______________________
WAXING INTAKE FORM
Name _______________________________________ Phone (____) ______________ DOB ____________
*Cell phone provider _________________ (for text confirmations)
Address _______________________________________ City ______________ State ______ Zip ________
Email ____________________________________
Would you like to receive emails on monthly specials or discounts? Yes
No
How did you hear about us (family/friend’s name, internet search, etc.)? __________________________
Occupation ____________________________________________________ Male _______ Female _______
Emergency Contact ______________________________________ Phone (_____) _____________________
Have you used any of the following in the last 48 hours?
Check all the following that apply:
 Alpha Hydroxy Acid
 Glycolic Acid
 Treated for skin cancer?
 Diabetic
 Retin-A or Renova
 Accutane
 Allergic to latex
 Skin sensitivity
 Tanning bed
 Granular scrub/polish
 Any open wounds, sores, skin irritation? ______
 Benzoyl Peroxide
 Salicylic Acid
_________________________________________
 Using skin thinning products/drugs?
 Acne
 Dermatitis
 Eczema
 Seborrhea
 Psoriasis
 Herpes Simplex
Are you currently taking any medications?  Yes  No
*If yes, please list: __________________________________________________________________________________
Waxing for hair removal, particularly on the face carries risks. These risks may include redness, bruising and lifting of
the skin.
These conditions may be exacerbated by the use of certain pharmaceuticals and cosmetics, particularly those for anti-
aging and anti-acne treatments. Examples of these are retinoid, Retin-A, Renova, Accutane, and alpha hydroxyl acids
(AHA’s) like glycolic acid. Face waxing should be avoided when using these products.
Certain prescription medications may aggravate the skin when waxed, particularly those causing photo-sensitivity
(sensitive to sunlight). Examples of these are many antibiotics, such as tetracycline, and blood thinners such as Warfarin,
which may cause an individual to bruise easily.
Clients who are receiving aesthetic and dermatological peeling treatments may also experience redness and skin lifting
from waxing and therefore should avoid waxing while undergoing such treatments.
The use of tanning booths can also contraindicate waxing. Waxing should not be done 24 hours before or after tanning.
It should also not be done on an area that still shows an erythema (redness) from tanning.
Because the fields of pharmacology and dermatology are continually changing and expanding, there may be products
and drugs that cause negative reactions to waxing that have yet to be documented.
I understand, have read and completed this questionnaire truthfully. I understand that withholding information or providing
misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are
voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I further
understand that the work of the esthetician should not be confused as a substitute for medical examination, diagnosis, or treatment and
that nothing said in the course of the session should be construed as such. I agree to keep this institution informed as to any changes
in my medical profile. I also understand that by scheduling future appointments, I am liable for payment of said appointments if I fail to
cancel within the 24 hours stated in Fusion’s company policy. I understand and agree that I will be responsible for paying 100% of the
service fee for any no-showed or late cancelled appointments. I agree that Fusion will deduct this from my credit card, a gift card, or
series on file at their discretion if missed or cancelled appointment is not filled by another client. This policy is enforced in our desire to
be effective and fair to all clients and out of consideration for our therapist’s precious time as they do work on commission and as
Fusion does have a constant running waiting list. By signing this form, I agree to all terms listed on this form.
Signature ____________________________________________ Print Name _______________________________________________________ Date _______________________