Melanin Rose Beauty Bar
Intake & Consent Form
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Occupation
Address
How did you hear about us?
Are you currently under a Dermatologist's care?
Are you currently using any prescribed, or over the counter topical medications?
Yes
No
If yes, please explain
Are you currently or have you ever taken accutane?
Yes
No
Are you currently undergoing chemotherapy or radiation?
Yes
No
Are you pregnant? On or near your menstrual cycle?
Yes
No
Have you stopped shaving the desired wax area in the last three weeks?
Yes
No
Please check if you have any of the following illnesses?
Allergies
Auto Immune Disease
Diabetes
Hemophillis
Herpes
Lupus
Roacea
Skin Cancer
MRSA
Have you used any of the following in the last 48-72 hours?
Tanning Bed
AHA/BHA
Scrubs or Peel
Benzoyl Peroxide
Retin-A
Differin
Bleaching Creams
Blood Thinner
Antibiotics
Birth Control Meds
Renova
Signature
*
Date
*
-
Month
-
Day
Year
Date
Print
Submit
Clear All Questions
Should be Empty: