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Waxing Intake Form
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Please select who will be participating...
Adult
Minor(s)
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First
Client's
Name
First Name
*
Last Name
*
Phone
*
First
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
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First
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
First
Client's
Signature
*
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Second
Client's
Name
First Name
*
Last Name
*
Second
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
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- Year -
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1912
Second
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Third
Client's
Name
First Name
*
Last Name
*
Third
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
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- Year -
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1914
1913
1912
Third
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Fourth
Client's
Name
First Name
*
Last Name
*
Fourth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
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- Year -
2021
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1918
1917
1916
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1914
1913
1912
Fourth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Fifth
Client's
Name
First Name
*
Last Name
*
Fifth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
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31
- Year -
2021
2020
2019
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1918
1917
1916
1915
1914
1913
1912
Fifth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Sixth
Client's
Name
First Name
*
Last Name
*
Sixth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
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11
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31
- Year -
2021
2020
2019
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2016
2015
2014
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2012
2011
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1981
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1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Sixth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Seventh
Client's
Name
First Name
*
Last Name
*
Seventh
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
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31
- Year -
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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1981
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1917
1916
1915
1914
1913
1912
Seventh
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Eighth
Client's
Name
First Name
*
Last Name
*
Eighth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
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30
31
- Year -
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1984
1983
1982
1981
1980
1979
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1977
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1952
1951
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1948
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1935
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1931
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1929
1928
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Eighth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Ninth
Client's
Name
First Name
*
Last Name
*
Ninth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
4
5
6
7
8
9
10
11
12
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14
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26
27
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29
30
31
- Year -
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
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1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
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1967
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1952
1951
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1948
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1945
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1941
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1935
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1933
1932
1931
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1928
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Ninth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Tenth
Client's
Name
First Name
*
Last Name
*
Tenth
Client's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
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5
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- Year -
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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2005
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2002
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1991
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1987
1986
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1981
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1972
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1951
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1948
1947
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1945
1944
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1941
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1935
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1933
1932
1931
1930
1929
1928
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1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Tenth
Client's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Parent or Guardian's
Email Address
Email
*
Confirm Email
*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's
Name
First Name
*
Last Name
*
Phone
*
Parent or Guardian's
Date of Birth
*
- Month -
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
- Day -
1
2
3
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31
- Year -
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
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2003
2002
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1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
Parent or Guardian's
Information
When did you last shave?
When is your menstrual cycle's start date?
Do you have or are prone to?
Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Bruising
Do you have any allergies?
*
No
Yes
If yes, please list:
Are you Diabetic?
*
No
Yes
Have you ever been treated for cancer?
*
No
Yes
Have you used any of the following in the last 72 hours?
Retin-A
Accutane
Alpha-hydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Have you used any skin thinning medications?
*
No
Yes
If yes, please list:
Do you use a tanning bed?
*
No
Yes
Are you allergic to anything?
Parent or Guardian's
Signature
*
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Electronic Signature Consent
*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.
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