BEAUTÉLANIN™  •  WAXING SERVICES

Waxing Assessment & Consent

Barrier-Conscious  •  Melanin-Conscious  •  Client-Centered

Part One
1

Client Information

2

Waxing History

Have you received waxing services before?

Have you ever experienced any of the following after waxing? Check all that apply

3

Current Skin & Barrier Status

Within the last 30 days, have you experienced: Check all that apply

Do you currently have any active breakouts, irritation, rashes, cuts, or open areas in the treatment region?

4

Pigment Response History

After irritation, acne, injury, insect bites, or hair removal, does your skin typically:

Have you previously experienced dark marks following waxing or hair removal?

5

Recent Treatments & Product Use

Have you used any of the following within the last 14 days? Check all that apply

6

Medical History

Do you currently have or have a history of: Check all that apply

7

Medications

8

Pregnancy & Nursing

Are you currently:

9

Dermatology Care

Are you currently under the care of a dermatologist?

10

Client Acknowledgment

I certify that the information provided above is accurate and complete to the best of my knowledge.

Part Two
11

Waxing Consent & Release

OUR APPROACH

At Beautélanin™, waxing services are performed using a barrier-conscious and melanin-conscious approach designed to prioritize skin integrity, comfort, and safety.

I understand that waxing is a form of mechanical exfoliation and may result in temporary:

Redness

Sensitivity

Irritation

Swelling

Pigment changes

Ingrown hairs

Temporary discomfort

I understand that individual responses vary based on factors including:

Skin sensitivity

Barrier condition

Inflammatory response

Product usage

Medications

Healing patterns

Pigment response

I understand that some individuals, particularly those with a history of post-inflammatory hyperpigmentation, may experience prolonged pigment changes following irritation or trauma.

I understand that it is my responsibility to disclose all relevant medical conditions, medications, skincare products, and recent treatments prior to receiving waxing services.

I understand that no treatment outcome can be guaranteed.

I have had the opportunity to ask questions and have received satisfactory answers.

I voluntarily consent to receive waxing services.

I have read, understood, and agree to the above consent and release statement. *

PLEASE NOTE

In addition to this online submission, a physical copy of this consent form will also be reviewed and signed in person (wet-ink signature) prior to your appointment, in accordance with our practice's record-keeping requirements.

I understand that I will also be asked to sign a physical copy of this consent form at the time of my appointment. *

Your information is confidential and used solely for treatment planning and safety assessment. It will not be shared or sold.

Something went wrong. Please try again.

✦

Thank you.

Your intake and consent form has been received. We look forward to your appointment. Please remember to bring a signed physical copy, or you'll be asked to sign one upon arrival.

ROOTED IN HAITIAN HERITAGE  •  POWERED BY NOIRSCIENCE™