Hair Removal Client Intake

Confidential Client Intake Form for Hair Removal
Name*
Birthday*
Address*
City*
State*
Zip Code*
Phone*
Email*
example@example.com
Occupation*
Emergency Contact Name*
Phone*
Would you like to be added to our email list for specials and discounts?*

YesNo
How did you hear about us*
Medical History. Please check all that apply:

AcneDiabetesFever BlistersHigh Blood PressureHypopigmentationLupusPregnantSeborrheaHype/Hypo ThyroidArthritisEczemaHeart ConditionHIVInsomniaSinus InfectionPsoriasisShinglesWartsDepressionEpilepsyHepatitisHyperpigmentationLow Blood PressureSurgeryRashesSkin CancerOther
Have you been treated for cancer?*

YesNo
If yes, when and what types of therapies were used?
Are you currently taking any medications?*

YesNo
If yes, please list
Do you have any allergies?*

YesNo
If yes, please explain
Please list any skin care products that you currently use*
Have you used any AHA products in the last 72 hours?*

YesNo
Are you using Retin-A, Renova, or Accutane?*

YesNo
AAre you using any other skin thinning products and/or drugs?*

YesNo
Are you exposed to the sun on a daily basis?*

YesNo
Do you currently have a sunburn?*

YesNo
Do you plan on spending more time in the sun soon?*

YesNo
Have you recently used a tanning bed?*

YesNo
Have you recently had a chemical or glycolic peel?*

YesNo
Have you waxed or sugared before?*

YesNo
If yes, when
If yes, did you have any adverse reactions?*

YesNo
If yes please explain
Do you have any abrasions, moles, or skin irritations in the areas being waxed or sugared?*

YesNo
If yes please explain
(Female clients) When is your next menstrual cycle due to begin? (For your own comfort, we recommend avoiding hair removal from two days before to two days after your cycle
By signing below, I agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any change in the above information. I agree that I do not have any condition( (s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
Signature*

Clear
Date*

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Date
Should be Empty:

Confidential Client Intake Form for Hair Removal