Confidential Client Hair Removal Questionnaire & Consent Form

WAXING CLIENT QUESTIONNAIRE + CONSENT FORM
DATE *

Month Day Year
NAME *

First Name Last Name
DATE OF BIRTH *
ADDRESS

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PHONE NUMBER *

Area Code Phone Number
E-MAIL *
Do I have permission to text/email updates, promotions, tips + tricks? *

YES NO
How did you hear about me? *
Are you a smoker? *

YES NO
Have you been under a doctor/ dentists care in the last 8 weeks? *

YES NO
If yes, when and for what?
Please list any medications or supplements taken in the last 8 weeks. *
Are you currently pregnant or nursing? If pregnant, how far along? *
Are you diabetic? (Type 1, 2 or gestational) *

YES NO
Have you used any Alpha Hydroxy Acids ( AHA) or Glycolic products in the past 72 hours? *

YES NO
If yes, please indicate which product(s).
Are you currently using Retin-A, Renova, or Accutane (an oral form of Vitamin A)? *

YES NO
If yes, which and when was the last time applied or taken?
Are you using any skin thinning or photosensitizing products? Topical or Oral. *

YES NO
If yes, which and when was the last time applied or taken?
Have you received any Botox, Dysport, Juvederm, or other dermal fillers in the last two weeks? *

YES NO
If yes, please provide further details (ie. which and when was the last time you received it?
Females ONLY: Last menstrual cycle. *
Any known allergies? Check all that apply. *

ASPIRIN TREE NUTS LATEX DAIRY FRUITS VEGETABLES SHELLFISH IODINE FRAGRANCES/ ESSENTIAL OILS OTHER NONE
If other, please specify.
Current skin care OTC and RX (very important for facial waxing clients). *
Have you used any medications (topical or oral) for acne/ acne control? *

YES NO
If yes, please specify.
Do you currently use a tanning bed? If yes, when was your last session? *
Do you ave a history of Herpes Oral (cold sores)? *

YES NO
Do you have a history of Genital Herpes? *

YES NO UNSURE
Do you have a history of Staph Infection? *

YES NO UNSURE
If yes, when did symptoms start and stop?
Do you have travel/ vacation plans that includes prolonged sun exposure within the next two weeks? If yes, when? *
Read Completely: Waxing may cause: Bruises, scabs, scarring, redness, hyper pigmentation, pimples or histamine reactions. Waxing of soft tissue(labia or scrotum) may cause the skin lifting or tearing resulting in the need for stitches or daily use of barrier ointment like aquaphor until healed. I understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications I must inform Laura Stockwell Licensed Aesthetician PRIOR to starting any service in the future. I understand that Blood Thinners, Accutane current or taken within 6 months, Chemotherapy/Radiation current or within 6 months, Surgeries within 6 weeks, Uncontrolled Diabetes, High Risk Pregnancy and or any other health condition/medication that your Esthetician deems is contraindicated to waxing/sugaring services I have read and understand post care instructions and I'm willing to follow recommendations made by my Aesthetician for post hair removal treatment to minimize or eliminate post hair removal complications (ingrown hair, bumps, infection, dry/cracked skin). I will notify my Aesthetician immediately with any questions or concerns in regards to my hair removal service. *

I have read the post care instructions and agree to adhere to them.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof. *

YES
Client Name *
Signature *
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WAXING CLIENT QUESTIONNAIRE + CONSENT FORM