Client Record Form

1
What is your name? * This field is required.Include legal first and last name.
First Name
Last Name
2
Primary Phone Number* This field is required.
Please enter a valid phone number.
3
Alternate Phone Number
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Emergency Contact Name* This field is required.
First Name
Last Name
7
Emergency Contact Number* This field is required.
Please enter a valid phone number.
8
Do you have a history of the following conditions? :* This field is required.Please check those that apply.
Circulatory disorder
Diabetes
Lupus
Eczema
Epilepsy
Seborrhea
Hemophilia
Dermatitis
Herpes
Psoriasis
Allergies; I will list my specific allergy in the appropriate space on this form.
Other autoimmune disease not listed above
I have other health conditions not listed & will elaborate in the appropriate space on this form.
I don't have any of the conditions listed above or any other health conditions.
9
Use this space to list health conditions you may have that were not already mentioned on this form. Please provide any additional information regarding your skin.
Huge
Large
Normal
Small
Ok
Ok
10
Please indicate if you currently have the following conditions and the location. If the condition does not apply to you, move to the next section.
11
Lack of or decreased skin sensation:Location
12
SunburnLocation
13
Scar TissueLocation
14
Mole(s)Location(s)
15
Fracture(s) or sprain(s)Location(s)
16
Varicose veinsLocation(s)
17
List all prescription medication you are currently taking:This information is kept confidential, but used for treatment purposes.
Huge
Large
Normal
Small
Ok
Ok
18
Are you pregnant?* This field is required.You may experience increased sensitivity during pregnancy
YESNO
19
Projected Due Date: Only pregnant clients need to answer this question
Date
Year
Month
Day
20
Are you currently using any of the following skin-care products?
Alpha-Hydroxy Acid (AHAs)
Accutane or Differin
Retin-A, Renova or other Retinol/Vitamin A derivative products
Glycolic acid
Any other product that treats acne
21
Are you currently undergoing any specialized facial or skin treatments?
Huge
Large
Normal
Small
Ok
Ok
22
I understand that it is my sole responsibility to notify the waxing tecnician of any changes to the above information before any waxing service.
23
Client's Full Name* This field is required. Type your full legal name in the spaces provided.
First Name
Middle Name
Last Name
24
Parent or Guardian Name Only for clients younger than 18 years of age: Print your full legal name in the spaces below. You will sign in the client signature box in place of the underage client.
First Name
Middle Name
Last Name
25
Client's Signature* This field is required.
Powered by Jotform SignClear
26
Date of Client's Signature* This field is required.List the day you are signing the form.
Date
Year
Month
Day
27
NOTICE TO CLIENTS: This client record form must be updated annually or when there are changes to your health, skincare or treatments, whichever comes first. Client file are kept on file for 5 years.

A technician will review your form, make notes and customize your appointment using the information provided. It is the client's responsibility to update the techician with any health, skincare and treatment changes PRIOR to each appointment, if applicable.

Click "SUBMIT" to complete this form.
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