Waxing Consultation Form Waxing Consultation Form Name(Required) First Last Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Are you under 18?(Required) Yes No Referred By I have not used a Retin-A, a Retinol OTC, Renova or any form of Alpha Hydroxy Acid (AHA)(Required) Yes No I have not had a professional or at home microdermabrasion, glycolic peel, or any other peels in the last 72 hours(Required) Yes No I have been off Accutane for at least twelve (12) months(Required) Yes No Are you using any other skin thinning products and or drugs?(Required) Yes No Do you use tanning beds or are you exposed to the sun on a regular basis?(Required) Yes No Do you plan to tan soon?(Required) Yes No Are you Diabetic?(Required) Yes No Do you smoke?(Required) Yes No Any known Allergies?(Required) Yes No Have you ever been waxed prior to today?(Required) Yes No Did you have any reactions? If so, please explainAre you currently taking medications? If so, please list all including over the counterWhat skin products do you regularly use on your skin?Please list any medical conditions your are currently be treated forDo you have any open lesions?(Required) Yes No Do you have an active herpes outbreak or cold sore?(Required) Yes No I agree to inform my service provider if I am on my menstrual cycle?(Required) Yes No agree to adhere to all skin care and safety protocols as recommended by my service provider. Including: no skin peels, no tanning, no sex, no swimming or hot tubs for 48 hours after waxing.(Required) Yes No I am aware that there are often inherent risks associated with waxing and I my have unfavorable results such as, but not limited to, allergic reactions, irritation, burning, redness, scarring, soreness, etc., by signing below I further agree that I will not hold my provider, or establishment responsible should any of the above occur. I further understand that it’s my responsibility to inform my provider if any of the above changes.(Required) Yes No We have the right to refuse services for all waxing services if proper hygiene is not followed for Brazilian/bikini waxes. Please use the provided wipes to cleanse the area.Patient Signature(Required)Date(Required) MM slash DD slash YYYY Daljeet Arora2022-09-28T18:14:31+00:00
