Wax Consultation Form Please note that the following personal, medical, and skin history is essential for your aesthetician to execute appropriate treatment procedures and not doing so, expected results may be affected. Name * First Name Last Name DOB * MM DD YYYY Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country How did you hear about us? Friend/ Relative Internet search Social Media Other How often do you have waxing done? Have you ever had a reaction to a waxing service? Yes No If yes, please describe: Do you have any tendencies to: Ingrown hair Scarring Bumps Hyperpigmentation Bruising Do you have any allergies? Yes No If yes, please describe: Are you using or taking: Accutane or Tetracycline Retinoids such as Retin-A, Renova or Diferin AHA/Alpha-Hydroxy Acid BHA/Beta-Hydroxy Acid Glycolic Acid Any other medications: Do you have Diabetes, Phlebitis or any skin irritations? Yes No Is your skin dry? Yes No I certify that I have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or the technician/esthetician/skin care professional from liability and assume full responsibility thereof. I agree I disagree Name First Name Last Name Signature Today Date MM DD YYYY Thank you!
