Waxing Consultation Form

Waxing Consultation Form
Date*

DayMonthYear
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Website / Online SearchYelpFacebookReferralOther
If Other, please let me know
Contraindications requiring medical permission

If medical permission cannot be obtained, the client must give written informed consent prior to treatment.
HaemophiliaOsteoporosisRecent OperationsInflamed nerveTrapped/Pinched nerveSevere varicose veinsMedical oedemaDiabetesAny condition being treated by a GP or another practionerNervous/psychotic conditionsCardiovascular conditions (thrombosis, hyper or hypo tension, heart conditions)I don't have any medical contraindications
Please feel free to go into more detail
Contraindications that restrict treatment

It is NOT recommended for you to go ahead with the appointment if you have any of the following contraindications.
FeverBells palsyLocalised swellingVaricose veinsBruisesInflammationHeat rashSunburnVascular skinInfectious or contagious diseasesCuts and/or abrasionsSelf tan or less than 48 hours after sun tanningRecent fractures (min. 3 months)Loss of skin sensationInfectious skin diseases & disordersUndiagnosed lumps & bumpsHairy molesHypersensitive skinScar tissue (2 years for major operations & 6 months for a small scar)Under the influence of alcohol or recreational drugsAny known allergies to pine rosins, jojoba oil, copolymers, lanolin, or beeswaxI have used retinol in the last 7-10 daysI don't have any contraindications that restrict treatment
Please feel free to go into more detail
LegsUnderarmsArmsLipBum cheeksBikini LineBrazilian/HollywoodBackEyebrows
YesNo
YesNoN/A
If yes, what kind
YesNoRecently had a baby and am breastfeedingN/A
YesNoN/A
If yes, please specify
YesNo
If yes, please specify
I GIVE PERMISSION TO MY AESTHETICIAN, ANGELA AT BARE AND NEUTRAL LTD, TO PERFORM THE WAXING PROCEDURE I HAVE CHOSEN. I FULLY UNDERSTAND THE QUESTIONS I HAVE BEEN ASKED AND I HAVE ANSWERED THEM ACCURATELY. I KNOW THAT BRUISING, SKIN LIFTING AND INGROWN HAIRS CAN OCCUR AS A RESULT OF WAXING. I UNDERSTAND ANY FALSE INFORMATION GIVEN MAY LEAD TO UNDESIRED RESULTS AND COMPLICATIONS AND MY AESTHETICIAN, ANGELA AT BARE AND NEUTRAL LTD, WILL NOT BE HELD RESPONSIBLE. I KNOW THAT IT IS MY RESPONSIBILITY TO ALERT MY AESTHETICIAN, ANGELA AT BARE AND NEUTRAL LTD, ABOUT ANY RECENT SURGERIES OR SKIN RESURFACING PROCEDURES AS WELL AS ANY MEDICATION I AM TAKING THAT MAY AFFECT THE PROCESS. I UNDERSTAND WAXING CAN CAUSE REDNESS, IRRITATION, PIMPLES AND BUMPS. I UNDERSTAND THAT MY AESTHETICIAN, ANGELA AT BARE AND NEUTRAL LTD, WILL TAKE EVERY PRECAUTION TO MINIMISE, ELIMINATE AND/OR PREVENT NEGATIVE REACTIONS AS MUCH AS POSSIBLE. I WILL HOLD MY AESTHETICIAN, ANGELA AT BARE AND NEUTRAL LTD, HARMLESS FROM ANY LIABILITY THAT MAY RESULT FROM THE TREATMENT I HAVE CHOSEN.
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Waxing Consultation Form

Contraindications requiring medical permission

Contraindications that restrict treatment