Health Questionnaire

Contact information:
theebrownsugarfairy@gmail.com

Date*

Full Name*

First NameLast Name

Age*

Birth Date*

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Phone Number*

Area CodePhone Number

Have you used Alpha Hydroxy Acid (AHA) or Glycolic products in the past 48 to 72 hours?*

YesNo

Are you using Retin-A, Renova or Accutane?*

YesNo

Do you have varicose or spider veins?*

YesNo

Are you exposed to the sun on a daily basis or will you be spending time in the sun soon?*

YesNo

What method of hair removal do you currently use?*

Do you suffer from any medical problems (Diabetes,High blood pressure) ?*

YesNo

Are you pregnant?*

YesNo

Have you ever had any adverse reaction to any skin care products?*

YesNo

Do you have any known allergies?*

YesNo

If so, please state your allergies here*

Are you currently on your menstrual cycle?*

YesNo

Are you currently taking medications? If so, please list all (Including over the counter drugs/Herbal supplements...*

Do you have any contraindications that may restrict your treatment?*

I give my permission to The Brown Sugar Fairy to perform the sugaring or henna brow treatment we have discussed. I understand that my therapist will take every precaution to ensure a safe and comfortable experience while minimizing the risk of any adverse reactions.

I have provided accurate information regarding any allergies, medications, or products I am currently using, whether ingested or applied topically. I confirm that I did not experience any adverse reactions during my patch test, and I acknowledge that the same brand of products will be used during my treatment.

For clients who have not completed a patch test:
I understand that choosing to proceed without a patch test may increase the risk of an unexpected reaction. While my therapist will use high-quality products and take all necessary precautions, I acknowledge that The Brown Sugar Fairycannot be held liable for any potential reactions that may occur.

I am aware of the potential risks and choose to proceed with the treatment at my own discretion.

Please sign here*

The Brown Sugar Fairy

Body Sugaring Hair Removal & Henna Treatment

Vitals

Thank you!! Let's get you sugared!!