The following information is required for your health and safety

Name:

Date of birth:

Address:

Email:                                                                     Phone:

Occupation:

Drs name:                                                                               (Your Dr will not be notified without your written consent)

Drs address:

 

It is vital that you inform me of any medical issues, as certain conditions mean you cannot be waxed. Please tick next to any of the folllowing if you have them

 

Medications/under care of a Dr

Skin disorders

Sunburn or heat allergies

Use of steroid creams or medication that thins the skin

Use of vitamin A skin care, glycolic acid or other AHA/BHA products

Use of roaccutane or acne treatments

Recent dermabrasion or laser treatment

Sensitive skin

Nerve damage

Allergies to nuts, essential oils, lanolin, sticking plasters etc.

Oedema or other swellings in treatment areas

Diabetes

Other areas of tenderness to be avoided

Recent injuries

Recent scar tissue, cuts, bruises to treament areas

Easily bruised, sensitive or highly reactive skin

Epilepsy, fits or fainting attacks

Circulation issues

Heart conditions

Varicose veins

Haemophilia

Low blood pressure

High blood pressure

Joint mobility issues

PREVIOUS REACTIONS TO WAXING

 

I confirm that the information given above is correct and complete, and give consent to the therapy I am receiving. I have read and understood the pre care and after care advice and the possible temporary reactions that may occur with a waxing treatment, such as bloodspotting, sensitivity, skin removal, and the possible reactions with a massage, for example. I will follow the advice given by my therapist, and if any major issues occur, to seek medical advice.

These details will be kept confidential under the data protection act.

 

Signed client:

 

Signed therapist:

 

Date: