WaxingIntakeForm

201-994-9596

201-994-9596

BOOK AN APPOINTMENT

WaxingIntakeFormpixlgraphx2020-09-29T02:53:42-04:00

Name:*
Address:*
City:
State:*
Zip:
Main Telephone*
DOB
Date Format: MM slash DD slash YYYY
Referred by:
Emergency Contact
Email Address:*
Please take a moment to carefully read the following information & sign where indicated
Have you been seen by a dermatologist?*
- Yes
- No
If yes, what reason?
Do you take any medications regularly. Including hormones, vitamins, etc?*
- Yes
- No
If yes, Please list:
Are you taking Accutane or any other acne medications?*
- Yes
- No
If yes, how long:
Do you use Retin_A, Renova, other topical vitamin A, or hidroquinone?*
- Yes
- No
Do you have any allergies?*
- Yes
- No
If yes, please list:
Are you pregnant or lactating?*
- Yes
- No
Have you had any of the following procedures? Please circle all that apply:*
- Laser resurfacing
- Light Chemical peel
- Medium/Heavy chemical peel
Do you ever experience tightness or flaking of your skin?*
- Yes
- No
Do you tan or frequently attend tanning booths?*
- Yes
- No
Do you have a history of fever blisters or cold sores?*
- Yes
- No
I, , am am not presently using:
*
- Retin_A or any other topical vitamin A
- Accutane or any other acne medication
- Any exfoliant or hydroxyl-based products
- Any medications such as cortisone, blood thinners, or diabetic medication
Please write initials to indicate acceptance below
Client's Signature*

4000 Riverside Station blvd. 4th floor Secaucus, New Jersey, 07094

201-994-9596