Waxing Intake Form printable pdf download

Waxing Intake Form

Health & Wellness

Waxing Intake Form

Name_______________________________________________

Are you currently using or have ever used the following on your skin:

Accutane – if yes, when? ___________________________________________________

Retin-A/Retinol/Differin/Renova – if yes, when? ________________________________

Metrogel – if yes, when? ___________________________________________________

AHA aka Alph-Hydroxy Acids (glycolics, lactic, etc.) ____________________________

BHA aka Beta Hydroxy Acids (salicylic) - if yes, when? __________________________

BPO (Benzoyl Peroxide) – if yes, when? ______________________________________

Hydroquinone medications (Eldoquin forte, Melanex, Soloquin, etc.) - if yes, when?

_______________________________________________________________________

Do you currently tan in a tanning bed – if yes, when? ____________________________

Do you keloid (raised scar for a cut or burn)? ___________________________________

Have you ever had any irritations or problems with past waxings? If yes, explain______

_______________________________________________________________________

Have you ever been diagnosed by a dermatologist for having eczema or Psoriasis? _____

Have you received any facial treatments within 10 days of this present waxing session - if

yes, when? ______________________________________________________________

If appointment is for body waxing, are there any varicose veins present? _____________

Have you ever been diagnosed with diabetes (types I or II)? _______________________

Waxing Intake Form