My Waxing System would like to thank you for taking the time to answer our specific questions. This Confidential Consultation Card enables technicians to adapt the waxing treatments to your skin conditions as we are working with HARD WAX and STRIP WAX. MY WAXING SYSTEM will offer you the highest quality of customer service.

- Have you been waxed before? Yes / No
- What areas? __________________________________ Any problems?____________________________

- Do you take any of the following products?
* Accutane:Yes/ No Oral acne drug. Skin becomes fragile and dehydrated, skin is already exfoliated.
* Differin: Yes/ No Topical cream or gel used to treat acne. Skin becomes fragile and dehydrated, skin is already exfoliated.
* Retin-A: Yes/ No A cream containing a Vitamin A derivative and tretinoin, used in the treatment of acne and the reduction of the fine lines associated with aging. Skin becomes fragile and dehydrated, skin is already exfoliated.
*Tetracycline: Yes/ No. A broad-spectrum antibiotic used in acne treatment. Waxing can cause an adverse reaction.
* Blood thinners : Yes/ No Along with drugs to treat epilepsy , cause easy bruising.

- Please state if you have had any of the following exfoliation procedures. Yes / No
* glycolic acid: Yes/ No Wait of 72 hours is obligatory.
*AHA peel Yes/ No Wait of 72 hours is obligatory.
* micro-dermabration Yes/No
* other major exfoliation procedures Yes/ No

-Have you had any laser resurfacing? Yes / No

-Have you had any skin cancer or removal of skin cancer? Yes / No
If yes, state location………………………………

- Are you pregnant? Yes / No

- Do you have Hemophilia? Blood disorder? Yes/ No Waxing is contraindicated

- Are you on your menstrual cycle? Yes / No

- Do you have any moles, warts, abrasions, skin irritations or skin inflammations in the areas to be waxed?
Yes / No

- Any known allergies? Yes / No

- When was your last sun or tanning bed exposure? ……………………………….
- I am aware that redness or irritation may occur after any waxing treatment. ……………………………….

This is to certify that I, undersigned, consent to the performing of the waxing treatment.
The above information is in my knowledge accurate.

Client Name: _________________________________Technician's signature: _________________________
Address: ____________________________________________________________________
Phone: _____________________ Date: _____________ Signature ______________________________

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