Marmalade

skin

Please fill out the following consent form to pre register for waxing services

First Name

Email Address

Last Name

Date of Birth

Phone

What waxing service are you receiving?

Have you waxed before?

Yes

No

If yes, how long ago?

Have you shaved the area to be waxed recently?

Yes

No

If yes, how long ago?

Are you prone to any of the follwing?

Ingrown Hair

Hyperpigmentation

Skin sensitivity/Allergic reactions

None

Are you diabetic?

Yes

No

Are you using any skin thinning products or medications? If yes please list

Any other illness or condition you are presently being treated for by a doctor?

I declare that the info I’ve provided is accurate & complete

Your Signature

Date

Thanks for submitting!

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