Confidential Waxing Consultation Card Form

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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____________________

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