Confidential Waxing Consultation Card Form printable pdf download

Confidential Waxing Consultation Card

Name_______________________________ Technicians Name_________________________

Date and Time of Treatment______________________________________________________

Client Analysis

Have you been waxed before? _____________ What area?_____________________________

Any problems? _________________________________________________________________

Do you take or use any products that contain the following:

Isotretinoin____ Tetracycline____ Retinoic Acid____ AHA Glycolic Acid____ Hydroquinone_____

Have you recently had any type of chemical or glycolic peel? Yes_____ No_____

If glycolic, what percentage? _____ If chemical, please explain___________________________

Any recent surgery or dermabrasion? Yes_____ No_____

Any skin cancer or removal of skin cancer? Yes_____ No_____

Are you pregnant? Yes_____ No_____ Are you a hemophiliac? Yes_____ No_____

Are you on your menstrual cycle? Yes_____ No_____

Are you on any medications, including birth control? If yes, list: ___________________________

How would you rate your sensitivity to pain? Low_____ Medium_____ High_____

Do you have any moles, warts, abrasions, skin irritations or skin inflammations in the areas to be

waxed? Yes_____ No_____ If yes, please list: ________________________________________

Do you have any allergies? _______________________________________________________

Have you been exposed to any tanning method in the past 24 hours? Yes_____ No_____

Have you taken any blood thinners, aspirin or any anticoagulating medication within the past 24

hours? Yes_____ No_____

In an effort to make your waxing experience as comfortable as possible, please supply your wax

technician with all the necessary details in regard to past waxing procedures or health information

not requested on this form.

Release for Waxing Service

I understand that the waxing service I have requested involves the application of heated products

that may cause an adverse reaction to my hair, skin or body on which the service is performed. I

fully understand that this establishment and its agents may refuse to perform the treatment I have

requested if I have answered “yes” to any of the above questions. I have read the before-and-

after procedures sheet provided to me by my technician and understand that failure to follow

these instructions could result in an adverse reaction that may cause injury or damage to my skin.

I hereby release this establishment, its agents and suppliers from any and all damage or injury

that may result from the treatment I requested. I further agree that I am over the age of 18 years

old.

Client signature________________________________________ Date____________________

Confidential Waxing Consultation Card Form