Skin care profile

Waxing Profile & Release Form
All information given will be kept confidential and used only by service professionals. Have you ever had waxing done before? Have you ever had a reaction or breakouts from any waxing? Have you used any products in the area to be waxed? Do you currently tan (indoor or outdoor)? Date last tanned Do you develop cold sores/fever blisters? Date of last outbreak Have you ever used any topical prescription products? (i.e. Renova, Differin, Tazorac, Retin-A, etc.) Have you ever used Accutane? Date of last use ____ Have you ever had any facial injectables? (i.e. Botox, Restylane, Juvederm, etc.) Have you ever had advanced esthetic treatments performed? (i.e. microderm, dermaplaning, chemical peels, laser, IPL, etc.) Are you currently taking any medications, vitamins or supplements? Do you have any known allergies? (i.e. seasonal, milk, sulfa, others) Prior to receiving this treatment, I have been candid in revealing any condition that may have bearing on this procedure, including those listed above and any conditions not listed. I understand that for the first 48 hours after waxing, I must avoid prolonged sun exposure and wear at least an SPF 25. I further understand that some redness, irritation, ingrown hairs, and small white bumps may occur. I understand that waxing may stimulate the activity of cold sores or fever blisters in individuals prone to them. I understand the procedure that will be performed today, and I will not hold Dolce Salon & Spa or its employees liable for any type of reaction that may occur. I understand that should any of this information change, I should inform my professional prior to my treatment. Client Signature Professional Name
Service(s) brow lip chin face uarm full arm half arm full leg half leg braz bikini ($_____) other Any changes to previous info given (prescriptions, allergies, cold sores/fever blisters, etc.)? Note changes & initial reverse Protocol oil scm soft wax hard wax oil scm fin spf other Professional Name
Service(s) brow lip chin face uarm full arm half arm full leg half leg braz bikini ($_____) other Any changes to previous info given (prescriptions, allergies, cold sores/fever blisters, etc.)? Note changes & initial reverse Protocol oil scm soft wax hard wax oil scm fin spf other Professional Name
Service(s) brow lip chin face uarm full arm half arm full leg half leg braz bikini ($_____) other Any changes to previous info given (prescriptions, allergies, cold sores/fever blisters, etc.)? Note changes & initial reverse Protocol oil scm soft wax hard wax oil scm fin spf other Professional Name
Service(s) brow lip chin face uarm full arm half arm full leg half leg braz bikini ($_____) other Any changes to previous info given (prescriptions, allergies, cold sores/fever blisters, etc.)? Note changes & initial reverse Protocol oil scm soft wax hard wax oil scm fin spf other Professional Name
Service(s) brow lip chin face uarm full arm half arm full leg half leg braz bikini ($_____) other Any changes to previous info given (prescriptions, allergies, cold sores/fever blisters, etc.)? Note changes & initial reverse Protocol oil scm soft wax hard wax oil scm fin spf other

Source: http://drupal.dcc.coeusblue.net/sites/default/files/pdfs/Dolces-Waxing-Profile_9.11.pdf