Waxing Treatment Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Year
Month
Day
3
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
4
Phone Number* This field is required.
Area Code
Phone Number
5
Emergency Contact* This field is required.
First Name
Last Name
6
Phone Number* This field is required.
Area Code
Phone Number
7
Are you on any medication?* This field is required.
YesNo
8
If yes, which ones?
9
Do you exercise?
YesNo
10
If yes, how many days per week?
11
Do you have or have had any of the following conditions? If yes, please select them:
Aids/HIV
Cold Sores/Fever Blisters
Eczema/Psoriasis
Hepatitis
Herpes
Varicose Veins
Cancer
Diabetes
Other skin irritation
None
12
Any known allergies?* This field is required.
YesNo
13
If so, which one?
14
List any medications you take regularly, including vitamins, herbal supplements, aspirin:
15
Any other illness/condition:
16
*When is your next menstrual cycle due to begin?*
17
*Are you pregnant?*
YesNo
18
Do you have any tendencies to:
Ingrown Hair
Scarring
Bumps
Bruising
Hyperpigmentation
19
Have you used any Alpha Hydroxy Acid (AHA) glycolic products in the past 72 hours?* This field is required.
YesNo
20
Are you using Retin-A, Renova or Accutane?* This field is required.
YesNo
21
Are you exposed to the sun on a daily basis?* This field is required.
YesNo
22
Do you plan to spend more time in the sun soon?* This field is required.
YesNo
23
Do you use a tanning bed?* This field is required.
YesNo
24
Have you ever had a waxing treatment before?* This field is required.
YesNo
25
Have you ever had a reaction to waxing?* This field is required.
YesNo
26
What skin products do you regularly use on your skin?
27
What service would you like:* This field is required.
Brows
Lip
Chin
Full Face
Side Burns
Full Arms
Half Arms
Underarms
Back/shoulders
Abdomen
Chest
Full Legs
Half Legs
Other
28
By signing below, you agree the following:

I have completed this form truthfully and to be the best of my knowledge, I agree to inform the technician of any changes in the information above. I agree to waive all liabilities toward my technician for any injury or damages incurred due to any mispresentation of my health history.
29
Signature* This field is required.
30
Date* This field is required.
Date
Year
Month
Day
Should be Empty: