Name: • Date of birth:
Email: • Mobile:
The information on this form is required so that I can provide you with a safe and effective treatment. Any details you supply are treated in the strictest of confidence and are never shared with anyone else, unless I am required to do so by law.
Please indicate if any of the following apply to you:
Heart conditions (e.g. recent heart attack, high or low blood pressure, etc.): YesNo
Blood disorders or medication (e.g. swollen veins, blood thinners, clotting disorder, etc.): YesNo
Conditions or medication affecting your immune system (e.g. diabetes, cancer treatment, etc.): YesNo
Skin disorders or infections in the treatment area (e.g. eczema, psoriasis, warts, ringworm, scabies, etc.): YesNo
Nerve damage or conditions affecting skin sensitivity (e.g. multiple sclerosis, fibromyalgia, sciatica, etc.): YesNo
Recent surgery, piercings or tattoos in the treatment area: YesNo
Recent skin peel, dermabrasion, laser, IPL or other aesthetic procedures in the treatment area: YesNo
Scar tissue, sunburn, swelling, injuries or areas of tenderness to be avoided: YesNo
Easily bruised, sensitive or highly reactive skin: YesNo
Allergies or intolerances (e.g. to sticking plasters, lanolin, aspirin, nuts, essential oils, etc.): YesNo
Currently using retinoids or exfoliating acids in the treatment area: YesNo
Use of Roaccutane, Retin-A, Renova, Differin or other acne products in the last 6 months: YesNo
Use of steroid creams or medication in the last 3 months: YesNo
Joint or mobility problems: YesNo
Pregnant or trying to conceive: YesNo
If you have answered yes to any of the above questions, please give further details:
Client declaration:
I confirm that the information I have provided above is true to the best of my knowledge and belief. I agree to notify my therapist of any changes. I have been fully informed about the expected results and effects of waxing and agree to follow all aftercare advice provided by my therapist.
