"Waxing Questionnaire & Consent Form"

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Waxing Questionnaire & Consent Form
Name ___________________________________________________________ D/O/B ______________
Address ______________________________________________________________________________
Mobile Phone _______________________________ Home Phone _______________________________
Email ________________________________________________________________________________
How did you hear about us? _________________________________________________________
What body part(s) are we waxing today? ___________________________________________________
When did you last shave? _______________________How often do you shave? _______________________
Occupation ___________________________________________________________________________
Circle Your Answers To The Questions Below
Medical:
MRSA
Herpes
AIDS
HPV
Allergies
* If I have Herpes or MRSA I may experience an outbreak.
Have you used any of the following in the last
Do you have or are you prone to?
48-72 hours?
Ingrown Hairs
Yes
No
Accutane
Yes
No
Scarring
Yes
No
Retin-A
Yes
No
Bumps
Yes
No
Alpha-Hydroxy Acid
Yes
No
Hyperpigmentation
Yes
No
Glycolic Acid
Yes
No
Bruising
Yes
No
Resorcinol
Yes
No
Allergies
Yes
No
Scrub or Peel
Yes
No
If yes, what to? __________________________
Have you used skin
Yes
No
Are you diabetic?
Yes
No
thinning medications?
Have you ever been treated
Yes
No
If so, which? ____________________________
for cancer?
Do you use a tanning bed?
Yes
No
Waxing Questionnaire & Consent Form
Name ___________________________________________________________ D/O/B ______________
Address ______________________________________________________________________________
Mobile Phone _______________________________ Home Phone _______________________________
Email ________________________________________________________________________________
How did you hear about us? _________________________________________________________
What body part(s) are we waxing today? ___________________________________________________
When did you last shave? _______________________How often do you shave? _______________________
Occupation ___________________________________________________________________________
Circle Your Answers To The Questions Below
Medical:
MRSA
Herpes
AIDS
HPV
Allergies
* If I have Herpes or MRSA I may experience an outbreak.
Have you used any of the following in the last
Do you have or are you prone to?
48-72 hours?
Ingrown Hairs
Yes
No
Accutane
Yes
No
Scarring
Yes
No
Retin-A
Yes
No
Bumps
Yes
No
Alpha-Hydroxy Acid
Yes
No
Hyperpigmentation
Yes
No
Glycolic Acid
Yes
No
Bruising
Yes
No
Resorcinol
Yes
No
Allergies
Yes
No
Scrub or Peel
Yes
No
If yes, what to? __________________________
Have you used skin
Yes
No
Are you diabetic?
Yes
No
thinning medications?
Have you ever been treated
Yes
No
If so, which? ____________________________
for cancer?
Do you use a tanning bed?
Yes
No
List all illnesses and/or conditions you are presently being treated for by a medical professional.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please note waxing does have certain side effects such as skin removal, redness, scabbing, bruising, scarring,
swelling, tenderness, hyperpigmentation, and/or pimples. Waxing of soft tissue may cause the skin to tear resulting
in the need for stitches. The most common occurrence of this is in a Brazilian bikini wax.
Ladies: During menstrual cycle - Because of water retention and for your comfort, avoid hair removal two days
before your cycle starts and two days after.
New use of any of the medications listed on the previous page increases the possibility of a reaction. Please inform
your Technician if you have begun taking any new medications since your last session.
I give permission to my Therapist to perform the waxing procedure we have discussed. I have given an accurate
account of the questions asked above including all known allergies, prescription drugs and/or products I am
currently ingesting or using topically. I understand my Technician will take every precaution to minimize or
eliminate negative reactions.
I have read and understand the post-treatment home care instructions.
I am willing to follow the
recommendations made by my Technician for a home care regimen that can minimize or eliminate possible
negative reactions. In the event that I may have additional questions or concerns regarding my treatment or
suggested home product/post-treatment care, I will consult my Technician immediately.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I
certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for
discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the
Technician or Rejuvenation Spa & Laser Services responsible for any of my conditions that were present, but not
disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
Client’s Name
____________________________________________ Date ________________
Print
Client’s Name
____________________________________________ Date ________________
Signature
Technician
____________________________________________ Date ________________
Print
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