"Waxing Intake Form - Serenity Health&wellness"

ADVERTISEMENT
ADVERTISEMENT

Download "Waxing Intake Form - Serenity Health&wellness"

496 times
Rate (4.7 / 5) 30 votes
Health & Wellness
Waxing Intake Form
Name_______________________________________________
Are you currently using or have ever used the following on your skin:
Accutane – if yes, when? ___________________________________________________
Retin-A/Retinol/Differin/Renova – if yes, when? ________________________________
Metrogel – if yes, when? ___________________________________________________
AHA aka Alph-Hydroxy Acids (glycolics, lactic, etc.) ____________________________
BHA aka Beta Hydroxy Acids (salicylic) - if yes, when? __________________________
BPO (Benzoyl Peroxide) – if yes, when? ______________________________________
Hydroquinone medications (Eldoquin forte, Melanex, Soloquin, etc.) - if yes, when?
_______________________________________________________________________
Do you currently tan in a tanning bed – if yes, when? ____________________________
Do you keloid (raised scar for a cut or burn)? ___________________________________
Have you ever had any irritations or problems with past waxings? If yes, explain______
_______________________________________________________________________
Have you ever been diagnosed by a dermatologist for having eczema or Psoriasis? _____
Have you received any facial treatments within 10 days of this present waxing session - if
yes, when? ______________________________________________________________
If appointment is for body waxing, are there any varicose veins present? _____________
Have you ever been diagnosed with diabetes (types I or II)? _______________________
Health & Wellness
Waxing Intake Form
Name_______________________________________________
Are you currently using or have ever used the following on your skin:
Accutane – if yes, when? ___________________________________________________
Retin-A/Retinol/Differin/Renova – if yes, when? ________________________________
Metrogel – if yes, when? ___________________________________________________
AHA aka Alph-Hydroxy Acids (glycolics, lactic, etc.) ____________________________
BHA aka Beta Hydroxy Acids (salicylic) - if yes, when? __________________________
BPO (Benzoyl Peroxide) – if yes, when? ______________________________________
Hydroquinone medications (Eldoquin forte, Melanex, Soloquin, etc.) - if yes, when?
_______________________________________________________________________
Do you currently tan in a tanning bed – if yes, when? ____________________________
Do you keloid (raised scar for a cut or burn)? ___________________________________
Have you ever had any irritations or problems with past waxings? If yes, explain______
_______________________________________________________________________
Have you ever been diagnosed by a dermatologist for having eczema or Psoriasis? _____
Have you received any facial treatments within 10 days of this present waxing session - if
yes, when? ______________________________________________________________
If appointment is for body waxing, are there any varicose veins present? _____________
Have you ever been diagnosed with diabetes (types I or II)? _______________________
The answers are true to my knowledge. If anything were to change with my skincare
treatments or home care regimen, I will advise my waxing technician before my
waxing procedure.
Client Signature____________________________________ Date ____/_____/______
Continued Treatment Consent
Date
Initials
Tech’s Name Date
Initials
Tech’s Name
Page of 2