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Luna Beauty & Wellness
Client Intake & Consent Form – Waxing

Cancellation Policy - I agree and accept the 24 hour cancellation policy which states that a minimum of 24 hours’ notice must be given to cancel and/or reschedule an appointment. If I fail to do so I agree that I will pay Luna Beauty & Wellness the full amount for the service. If I have a gift certificate/voucher I agree to forfeit its value and pay the difference should there be a remaining balance.

Luna Beauty & Wellness reserves the right to refuse service. Any lewd/disrespectful/sexual/inappropriate comments or behavior will terminate the session and I will be liable for payment of the scheduled treatment. 

 

Female clients - Be aware due to water retention and for your own personal comfort, you may want to avoid hair removal two days before your cycle is due and two days after it is completed.

Please note that waxing does have certain side effects such as skin removal, redness, swelling tenderness, etc. I have read this waiver and understand completely. I give permission to my esthetician to perform the waxing procedure we have discussed and will hold Luna Beauty and Wellness harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold Luna Beauty & Wellness nor the esthetician performing this service responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Today's date: September 28, 2021

First Client's Name

First Name*

Middle Name

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
First Client's Signature*
Second Client's Name

First Name*

Middle Name

Last Name*
Second Client's Date of Birth*
Second Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Third Client's Name

First Name*

Middle Name

Last Name*
Third Client's Date of Birth*
Third Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Fourth Client's Name

First Name*

Middle Name

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Fifth Client's Name

First Name*

Middle Name

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Sixth Client's Name

First Name*

Middle Name

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Seventh Client's Name

First Name*

Middle Name

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Eighth Client's Name

First Name*

Middle Name

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Ninth Client's Name

First Name*

Middle Name

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Tenth Client's Name

First Name*

Middle Name

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
I confirm that I have read and understand all information on the applicable forms for this treatment or service and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree and give permission for my child to have the above services performed today and going forward as needed. I agree to supervise any home care procedures that are recommended as a result of the treatment. Clients under the age of 18 must be accompanied by a parent or legal guardian during the entire session.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

What are your preferred pronouns? *

Referred by *
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?*
No
Yes
Are you using Retin-a, Renova, or Accutane (oral form of Retin-a)*
No
Yes
Are you using any other skin thinning products and/or drugs?*
No
Yes
Are you exposed to the sun daily or are you considering spending more time in the sun soon?*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you a diabetic?*
No
Yes
Do you have any allergies to oils, fragrances, aspirin, fruits, nuts or any other ingredients?*
No
Yes

If yes, please explain
Are you currently taking medications?*
No
Yes

If so, please list all (including over the counter)
Do you currently exfoliate the area(s) that are being waxed today?*
No
Yes

Please list any illness/condition you are currently being treated for by a medical professional:
Parent or Guardian's Signature*
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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