New Waxing Clients - Makeup Glam With B

Date

Name *

First

Last

Date of Birth

Address

Address Line 1

City

State

Zip Code

Home Phone

Business Phone

Cell Phone

Email

Physician:

First

Last

Phone

Emergency Contact:

First

Last

Phone

Have you been under the care of a physician, dermatologist or other medical professional within the past year?

If "Yes", explain:

Any recent surgery, including plastic surgery?

If "Yes", explain:

Any skin cancer?

If "Yes", explain:

Have you had any piercings, tattoos, or permanent cosmetics?

If yes, where on your person?

Have you ever had a body spa treatment before?

If yes, when?

Have you had any of these health conditions in the past or present? (Please check all that apply)

Has your physician discussed concerns about raising your body temperature?

If yes, explain?