Waxing Consultation Form

Waxing Consultation Form

Please complete ALL information prior to appointment
Name

First NameLast Name
Date of birth

DayMonthYear
Date
Email
example@example.com
Gender
Phone Number

Area Code
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
General Practitioner/Doctors
Have you had waxing treatments previously?
Did you suffer any adverse reaction?
Have you any known skin allergies ?
Are you taking any medications?
Are you pregnant ?
Do you have hypersensitive skin?
If you have checked any of the below problems, then waxing treatment may be restricted or refused and you may be asked to contact your Doctor for advice.

Other
If 'Other' box is checked - please provide more information
Are you currently using any products that may contain:
Consultation Date & Time
I am providing my consent to complete the procedure and I am aware of the side effects of waxing to my skin during or after the procedure such as:
skin redness, swelling, skin irritation, bruises, or bumps.

I adhere to all the above statements I have completed.
Signature
Any Additional Information/Requests
Should be Empty: