Waxing Consultation & Consent Form
Personal Information
Full Name
Date of Birth
Phone Number
Email
Emergency Contact Name & Number:
How did you hear about us?
Referral by Someone Social Media Website Walk-in Other
Medical History
Please check all that apply:
Diabetes Blood-thinning medications Skin sensitivity Allergies (please list) Currently pregnant or nursing History of ingrown hairs Autoimmune disorder Hormonal imbalance Current or recent use of antibiotics Recent surgery or medical treatments Other medical conditions
Skin History & Contraindications
Please check if any apply within the past 30 days
Use of Accutane (must be discontinued for at least 6 months) Use of Retinol, Retin-A, Differin, Tretinoin Use of Alpha/Beta Hydroxy Acids (AHAs, BHAs) Chemical peel Laser or IPL treatment Sunburn Skin infections or open wounds Recent cosmetic injectables (Botox, fillers) Menstruating today (sensitivity may be higher)
Have you ever had a reaction to waxing before?
Yes No If yes, please describe:
Have you shaved the area within the last 48 hours?
Yes No
Waxing Areas (Check all being treated today)
Waxing Areas
Eyebrows Upper lip Chin Full face Underarms Arms Bikini Brazilian Legs Back Chest Other If Other, please describe:
Client Acknowledgement & Legal Consent
I, the undersigned, understand that waxing involves the removal of hair from the root using a warm or hard wax technique and may result in minor skin irritation, redness, bumps, or ingrown hairs.
I understand and agree to the following:
I have disclosed all relevant medical information, allergies, sensitivities, and skincare routines that may impact the waxing process or results.
I am aware that waxing should not be performed on sunburned, irritated, broken, or recently treated (e.g., chemically exfoliated or lasered) skin.
I understand that certain medications, including but not limited to Retin-A, Accutane, and antibiotics, can thin the skin and increase sensitivity and risk of injury.
I agree to follow the pre- and post-waxing care instructions provided by my esthetician.
I acknowledge that results vary depending on hair growth cycle, skin type, and adherence to aftercare.
I release Derma Direction and my esthetician from any liability associated with adverse reactions or complications, provided proper procedures were followed.
Yes, I voluntarily give my informed consent to receive waxing services at Derma Direction.
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