Intake Form-Client Waxing - Vibrate higher.

Name*

First Last

Birthdate*

Address*

Street Address Address Line 2 City State ZIP Code

Best phone number for you?*

Email*

Enter Email Confirm Email

Emergency Contact*

First Last

Emergency Contact Phone*

Who referred you?

First Last

What is the reason for your visit today?*

How may we contact you? Select all that apply.*

Email
Text Message
Phone Call

Are you under a Physician's care? If yes, please describe below.*

No
Yes

If Yes checked above, please describe here.

Please list any allergies:

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*

No
Yes

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?*

No
Yes

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*

No
Yes

Do you use a tanning bed?

No
Yes

Are you diabetic?*

No
Yes

Please list all medications, both oral and topical. Also list supplements.

Have you ever been treated for cancer? If yes, please describe when and what types of therapies below.*

No
Yes

If yes, please describe here.

What skin products do you regularly use on your skin?*

Which home products would you like more information on? Check all that apply.

Cleanser
Toner
Eye Cream
Serums
Moisturizer

What is your current home skin care regimen, AM & PM?*

I understand the information here is to aid the skin care therapist and it is not a substitute for medical care. I understand the questions and have answered them honestly and correctly.*

Acknowledge

I understand that Angelique Swann Esthetics & Wellness Solutions and staff do not diagnose illness, disease, or any other physical or mental disorder. I accept full responsibility of the use of Angelique Swann Esthetics & Wellness Solutions at my own risk, and to not hold Angelique Swann Esthetics & Wellness Solutions or staff liable for loss, damage or injury.*

Acknowledge

I understand that results are personable and not guaranteed.*

Acknowledge

I confirm that to the best of my knowledge that the answers given on client consultation form are correct and that I have not withheld any information that maybe relevant to my treatment at Angelique Swann Esthetics & Wellness Solutions.*

Acknowledge

I understand that I must provide at least 24 hours advance notice for the cancellation of an appointment.*

Acknowledge

Angelique Swann Esthetics & Wellness Solutions has a strict 24-hour cancellation policy. Your appointment time is reserved exclusively for you. Communication is crucial if you need to cancel or reschedule your appointment. In the event of a late cancellation the fee is the cost of your appointment or $50.00, whichever is less. If appointment is cancelled same day or no show, the fee is 100% of scheduled service. PLEASE NOTE: Saturday appointments now require a 3 day (72 hour) notice to reschedule or cancel. An invoice will be sent, which is due upon receipt. If I am able to replace appointment with a client on wait list, I am happy to waive the fee.*

Acknowledge

I understand there are risks associated with skincare and waxing treatments. Such as: redness, sensitivity, peeling, inflammation. Any additional concerns I will discuss with my practitioner.*

Acknowledge

Yes! I would love to be added to Angelique Swann Esthetics & Wellness Solutions monthly newsletter for relevant information, timely topics, and special savings offers to enhance your life.*

Acknowledge

Please note any additional information that may be of importance to your Licensed Esthetician regarding the spa treatment you may be receiving.

Signature (your name submitted below will be considered your electronic signature)*

First Last

Date Signed*

Client Waxing Intake Form

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