New Skincare/Wax Client Consultation Form

New Client Consultation Form

Skincare & Waxing Services
Date*

MonthDayYear
Name*

First NameLast Name
Date of Birth*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Website / Online SearchFacebookInstagramOtherReferral
If Referral, please list name
If Other, please let us know
Your Skin
What are your skin care goals?
Wrinkles / Fine LinesHyperpigmentation / Sun DamageAcne / Acne ScarringRedness / RosaceaAgingMelasmaSensitivityOther
Please feel free to go into more detail
YesNo
If Yes, when?
Cleanser / Face WashBar SoapFace Scrub / ExfoliantsTonerSerumsMoisturizerSunscreenEye Product(s)Lip Product(s)
Yes, currently usingYes, but not within the last 30 daysYes, but not within the last 6 monthsNoNot sure
Please specify which product or type, if you answered 'Yes, currently using' to above.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time and location.
Yes, within the last monthYes, within the last 2-3 monthsNo
YesNo
Your Health
Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersHerpesFrequent Cold SoresHIV/AIDSLupusDepression/AnxietyHepatitisHeadaches / MigrainesOtherNone
If you checked yes to any of these please provide further information. If not mark N/A
Wear contact lensesHave a pacemakerHave metal implantsHave body piercingsNo, not Applicable
If other, please list
AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
YesNo
If yes, please specify what and date last used
YesNoSocial
YesNo
YesNo
LowMediumHigh
FEMALE CLIENTS
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
MALE CLIENTS
Razor / Wet shaveElectricN/A
YesNoN/A
Post Skin Care/Waxing Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 30) should become part of your daily skin care regimen as skin can potentially become more sensitize to the sun as a result of this treatment. Do not apply additional exfoliating ingredients/products within at least 3 days of your service as over-exfoliation can result in irritation or further sensitivity. Enzyme peels, microdermabrasion, chemical peels, or facial waxing can result in skin flushing/redness or slight skin flaking or sensitivity for up to 1 week post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Payment will be made via cash, check, or credit/debit card. Tap pay is also available. Payment will be collected prior to the service beginning. Students are able to be tipped by the Client. Tips cannot be added to a credit or debit card.
The Client may not receive a refund for any service already performed except under certain extreme circumstances as determined solely by the instructor or school owner. Refunds will be given to the Client if they have already paid for a service that they are unable to receive and the service has not yet been given. No refunds on opened retail products are allowed. A refund may be given to the Client who returns an unopened retail product within 7 calendar days of purchase.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care student, instructor, or school from liability and assume full responsibility thereof. I understand that I am choosing to receive a service performed by a student. All students perform services under licensed instructor supervision.*

Yes
Signature*
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New Client Consultation Form

Your Skin

Your Health