Sugaring & Waxing Intake Form

Sugaring & Waxing Intake Form
Have you ever had a professional sugaring or waxing?

Yes No
Have you ever had an adverse reaction to sugaring or waxing?

Yes No
Have you had a peel, microdermabrasion, or tanned in the past 48hrs?

Yes No
Are you currently taking any medication?

Yes No
Please list all other medications you are currently on:
Do you have any allergies?

Yes No
List all allergies/allergens: (don't forget, product ingredients, foods, plant/herbs, latex etc)
Are you taking any medications? (Check all that apply)

Accutane Adapalene Alustra Avita Differin Tretinoin Isotretinoin Renova Retin A Tazarac Tazarotene Benzoyl Peroxide Retinol Antibiotics Heart Meds Acne Meds
List all other medication? (any medication can be a risk during hair removal)
Are any of these conditions present? (Check all that apply)

Varicose Veins Recent Surgery Sunburn Allergies Phlebitis Diabetes Capillaries Rash Scar Tissue Herpes Pregnancy Hypertension Chemotherapy AIDS/HIV Hepatitis Warts/HPV Menstrual Cycles Heart Condition Fungus Infection Ingrown Hair Moles Acne Stress Other
All Other conditions?
Did you consume any of the items below this week?

Yes No
Did you consume any of these items in the last 24hrs?

Tylenol Advil Pain Killers Lots of Fruit Vitamin C Supplement Multi-Vitamin Alcohol Sugar Caffeine Nicotine Medication Herbs Juices
Any items above being present can cause you to experience more discomfort, an increased chance of side effects like skin injury, bruising, scabbing or other complications. You must inform your practioner immediatelhy if any of the items above change at any time in-between services. Your intake information is important to keep up to date for your safety during hair removal or other services. Thank You.
My signature acknowledges that I have read and agree to receive the treatments or series of treatments listed above and I will adhere to all of the aforementioned statments that I have checked.
Name

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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