Hair Removal Client Consultation Assessment Form
This form is to be filled out prior to every wax service.
Today's Date
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Month
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Day
Year
Date
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list all medications that you take regularly. Include hormones and vitamins.
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Are you taking Accutane or any other acne medications? If so, for how long?
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Do you use Retin-A, Renova, other topical vitamin A, or hydroquinone? If yes, for how long?
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Do you have allergies? Are you allergic to any medications? If yes, please list allergies.
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Are you pregnant or lactating?
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Yes
No
I am an man, this does not apply to me
Have you had any of the following procedures in the area being treated?
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Laser Resurfacing
Light Chemical Peel
Medium/Heavy Chemical Peel
I have not had any of these procedures
Do you ever experience tightness or flaking of your skin?
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Yes
No
Have you recently taken Antibiotics?
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Yes
No
Do you have a history of fever blisters or cold sores?
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Yes
No
*By signing, I am stating that I AM or AM NOT presently using Retin-A or any other topical vitamin A, Accutane or any other acne medication, any exfoliant or hydroxyl-based products, any medications such as cortisone, antibiotics, blood thinners, or diabetic medication. I understand that any of the above are contraindicated for waxing and may result in skin irritation, peeling or hyperpigmentation. I understand that if I begin using any of the above products and do not inform my esthetician prior to hair removal, I am accepting full responsibility for any skin reactions. I acknowledge this release will operate as a release for future hair removal treatments received at Rich Revenge Beauty, LLC. Minor redness and sensitivity is normal for waxing. Avoid sun, heat, and certain products as directed for at least 24-48 hours after waxing. The hair removal process has been thoroughly explained to me, and I have had an opportunity to ask questions and receive satisfactory answers.
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Submit
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