Waxing Consent/Consult Form
Name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
How did you hear about WaxedbyIvyy?
Facebook/Instagram
Internet Search
Referral
Other
If referred, by who?
Have you had waxing treatments previously?
Yes
No
Did you suffer any adverse reaction?
Yes
No
Are you taking any medications?
*
Yes
No
If you answered YES to the question above, please list medications.
*
Do any of the following apply to you? If you have checked any of the boxes below, then waxing treatment may be restricted or refused and you may be asked to contact your Doctor for advice.
Allergies
Diabetes
High/low blood pressure
Varicose Veins
Heart Condition
Haemophilia
Epilepsy
Heart Condition
Radiation or Chemotherapy
Accutane
Any Additional Comments or Concerns
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: