Your health and wellness is our priority at Wax With D. Prior to your appointment, please submit the form below: Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * YOUR HEALTH WITHIN THE LAST YEAR, HAVE YOU BEEN UNDER A PHYSICIAN'S CARE? * Yes No PLEASE SPECIFY ANY HEALTH PROBLEMS YOU HAVE HAD IN THE PAST OR PRESENT. DO YOU HAVE A METAL IMPLANT, PACEMAKER, OR BODY PIERCINGS? * Yes No DO YOU HAVE A HEART MURMUR, SEIZURES, OR EPILEPSY? * Yes No YOUR SKIN DO YOU HAVE SKIN PROBLEMS PERTAINING TO YOUR FACE OR BODY? If yes, please specify. HAVE YOU EVER HAD A FACIAL BEFORE? If so, when? ARE YOU CURRENTLY USING PRODUCTS THAT CONTAIN THE FOLLOWING INGREDIENTS? Glycolic acid Lactic acid Any exfoliating scrubs Any hydroxy acid product Vitamin a derivatives such as retinol Retina-A or Retinoll Acutane Citric acid Resorcinol Benzoyl Peroxide Hydroquinone Tretinoin Topical Antibiotics Topical Steroids Differin HAVE YOU EVER HAD ANY OF THE FOLLOWING TREATMENTS? Chemical peels Laser resurfacing Facial cosmetic surgery Facial injectables Permanent cosmetics Light treatments Microdermabrasion Dermaplanning Extractions Electrolysis Laser hair removal Waxing IF YES TO THE ABOVE, IN THE LAST MONTH? WHAT ARE YOUR SKINCARE GOALS? DO YOU SPEND TIME IN THE SUN? * Yes No DO YOU OR HAVE YOU USED A TANNING BED? * Yes No DO YOU REMOVE YOUR MAKEUP AT NIGHT? * Yes No DO YOU USE SUNSCREENS? * Yes No WHAT TYPE OF SKINCARE PRODUCTS ARE YOU CURRENTLY USING? DO YOU OR HAVE YOU HAD ANY ALLERGIC REACTIONS TO ANY SKINCARE PRODUCTS THAT YOU ARE AWARE OF? HAVE YOU EVER HAD A HISTORY OF ACNE? IF SO, WHAT MEDICATIONS HAVE YOU BEEN PRESCRIBED? HAVE YOU EVER HAD ANY OF THE FOLLOWING CONDITIONS FROM: COLD SORES OR FEVER BLISTERS, ECZEMA, DERMATITIS, PSORIASIS, KELOID SCARRING, OPEN SORES OR LESIONS * Yes No FEMALE CLIENTS ONLY ARE YOU PREGNANT OR PLANNING TO BECOME PREGNANT? * Yes No I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS CONSULTATION CARD IS ACCURATE, TO THE BEST OF MY KNOWLEDGE, AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT WILL BE RELEVANT TO MY TREATMENT. * Provide a digital signature and date below: THIS CONSULTATION CARD IS TO CORRECTLY EVALUATE YOUR SPECIAL SKINCARE NEEDS. THIS INFORMATION IS CONFIDENTIAL AND MAY BE DISCLOSED TO ONLY STAFF MEMBERS, RISK MANAGEMENT, OR QUALITY IMPROVEMENT PERSONNEL TO ASSESS THE QUALITY OF CARE AND WILL NOT BE PASSED TO A THIRD PARTY. Thank you!
