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New Client info sheet

Name

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Date of Birth

Gender

Male

Female

Address

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City

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State

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Zip

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Phone

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E-mail

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Do you have 3 weeks or more of hair growth ?

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Have you had this wax service done before?

Yes

No

Within the past year, have you been cared for by

a physician

dermatologist

other medical professional

None

Any recent surgery, including plastic surgery?

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Have you had or have any of these conditions?

Cancer

Hormone imbalance

Systemic disease

High blood pressure

Thyroid condition

Diabetes

Eczema

Headaches (chronic)

Herpes

Immune disorders

Keloid scarring

Skin disease/skin lesions

None

List any medications you take regularly

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List any over the counter meds you take regularly

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Do you use any of the following products? These products/Rx may cause issues with the wax.

Retin-A

Renova

Adapalene Hydroxyl Acid

Deferin

Glycolic Acid

AHA

Salicylic Acid

Retinol

Vitamin A derivative products

Blood thinners (Warfin, NSAIDs, Heparin)

Currently on Cancer Treatments

None

Have you used them in the last 3-12 months?

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Have you used acne medication? When/ Which drug?

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Do you form thick/ raised scars from cuts/ burns?

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Do you have any of these skin conditions?

Hyper pigmentation (darkening of the skin)

Hypo pigmentation (lightening of the skin)

Marks after physical trauma

None

Ever had these after using skin products/ waxing?

Sun Sensitivity

Breakout

None

If yes to any, please explain

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Have you tanned in the last 24 hours ?

Yes

No

How did you hear about us?

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Comments

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