CLIENT ASSESSMENT FORM

(Sample form)
(assessment should be performed/reviewed prior to each treatment)
Name __________________________________________________________________________ Date __________
Phone ___________________________________ Address ______________________________________________
E-mail _________________________________________________________________________________________
Have you been waxed before? Yes ____ No ____
The following are potential contraindications for waxing:
Any chemical exfoliation treatment such as a glycolic acid peel or
any other AHA treatment? (wait at least two weeks before waxing): Yes ____ No ____ If yes, when: ________
Applied any topical products containing AHAs (glycolic or lactic acid),
BHAs (salicylic acid), or lightening or bleaching gels? (wait at least
48 hours; a week is better) Yes ____ No ____
Have you had microdermabrasion, laser resurfacing, light therapy, or
injectable treatments? (wait 4 weeks or longer—treatment dependent) Yes ____ No ____ If yes, when: ________
Are you taking acne drugs and/or using exfoliating topical products
such as Retin-A® or other vitamin A products ? (wait at least
3 months or longer—drug dependent) Yes ____ No ____ If yes, what type: ____
Exposure to continuous sun, or shaved, scrubbed, or experienced
any recent peeling or irritation in the last 48 hours? Yes ____ No ____
Skin treatments: ______________________________________________Date(s): _______________________________
Currently using, or has used, the following topical products on face and neck:
___________________________________________________________________________________________________
Medical conditions: _________________________________________________________________________________
Currently taking, or has taken, the following medications: ________________________________________________
Pregnant or lactating? Yes ____ No ____
Seen or seeing dermatologist? Yes ____ No ____ Date:________
Name of doctor: ____________________________________________________________________________________
Allergies to products or medications: __________________________________________________________________
History of fever blisters or cold sores? Yes ____ No ____
Tanning regime or use of tanning booths? ____________________________________ Frequency: _______________
Client initials: ______________

WAX TREATMENT RECORD

(esthetician to fill out chart notes on back of assessment form for each service)
Client Name: ______________________________________________________________________________________

Date Esthetician Wax Service Notes

9/8 Teresa Brow with soft wax New client: shaping for
more arch, close-set eyes
Tweezed chin
No redness

▲ FIGURE 11­–16  The client wax intake form.

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