Waxing Questionnaire & Consent Form
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2Waxing 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
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Parent category: Legal