Client Information And Consent Form: Waxing printable pdf download

CLIENT INFORMATION AND CONSENT FORM: WAXING

Name: _______________________________________ Date of Consultation: ______________________

Address: _____________________________________________________________________________

City: __________________________________________________ State: __________ Zip: ___________

Home: (_____)______________________________ Cell: (_____)________________________________

E-mail: ____________________________________ Date of birth: ________________________________

Known allergies: ____________________________ Medication: _________________________________

How did you find out about us? Referral / Internet / Other: _____________________________________

If referred by someone, please give his/her name: _____________________________________________

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past week?

Yes / No

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

Yes / No

Are you using any blood/skin thinning products and/or drugs?

Yes / No

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

Yes / No

Do you use tanning bed?

Yes / No. If yes, last time?: _______________________________________

Have you ever had any adverse reactions to waxing? _______ If yes, please explain: _________________

_____________________________________________________________________________________

Have you ever been treated for cancer? If yes, when and what types of therapies were used? __________

_____________________________________________________________________________________

Please list any other illness/condition you are currently being treated for by a medical professional: ______

_____________________________________________________________________________________

What is your menstrual cycle due date? _____________________

(Always allow five days for menstrual cycle. Because of

water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after is completed).

Client Information And Consent Form: Waxing