Wax Consultation

Name *

First Name

Last Name

Have you ever had professional waxing? *

Yes

No

Have you ever had an adverse reaction to waxing? *

Yes

No

N/A

Are you currently affected by any of the following:

Varicose veins

Sunburn

Diabetes

Recent Surgery

Rash

Allergies

Phlebitis

Recent Peels

Menstrual Cycle

Recent Scar Tissue

Distended Capillaries

Are you currently taking any of the following medicine:

Accutane

Retinol

Renova

Retin A

Tetracycline

Differin Gel

Any retinoid medication

Have you recently taken any blood thinners (including aspirin, alcohol, tylenol, presciptions, etc.)? *

Yes

No