Wax Questionnaire -   Auburn Skincare      3605 Orchard Street SE   Auburn, Wa 9092  (253) 333-0485
(Please print, fill out and bring with you to your appointment.)


Todayís 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 you have Herpes or MRSA you may experience an outbreak. __________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 understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications I must inform the professional PRIOR to starting any service in the future.

_____________________________________             _____________________________________
Esthetician 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 long enough to be pulled out by the root. Tweezing interrupts this from happening.

So we ask that you be patient for about 1 month, donít 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 and medications 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:  ________________________________________

 

Auburn Electrology, Skin & Nail Care - http://www.auburnskincare.com/