Client Consultation Form –
Remove Hair using Waxing Techniques
Client Name:
Address:
College Name:
College Number:
Learner Name:
Learner Number:
Date:
PERSONAL DETAILS
Age group: Under 20
20–30
30–40
Lifestyle: Active
Sedentary
Last visit to the doctor: Can’t remember
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
Profession:
Tel. No: Day
Eve
40–50
50–60
60+
CONTRAINDICATIONS REQUIRING MEDICAL PERMISSION – in circumstances where medical
permission cannot be obtained clients must give their informed consent in writing prior to treatment.
(select if/where appropriate):
Cardiovascular conditions (thrombosis, phlebitis,
Nervous/Psychotic conditions
hypertension, hypotension, heart conditions)
Recent operations
Haemophilia
Diabetes
Any condition already being treated by a GP or
Trapped/Pinched nerve
another practitioner
Inflamed nerve
Medical oedema
Severe varicose veins
Osteoporosis
CONTRAINDICTIONS THAT RESTRICT TREATMENT (select if/where appropriate)
Fever
Self tan
Infectious or contagious diseases
Heat rash
Under the influence of recreational drugs or
Hairy moles
alcohol
Hormonal implants
Any known allergies
Recent fractures (minimum 3 months)
Infectious skin diseases and disorders
Neuralgia
Undiagnosed lumps and bumps
Hypersensitive skin
Localised swelling
Loss of skin sensation
Inflammation
Vascular skin
Cuts
Hairy moles
Bruises
Varicose veins
Abrasions
48 hours after sun tanning
Scar tissues (2 years for major operation and 6
Bells Palsy
months for a small scar)
Abnormal hair growth
Sunburn
Patch Test:
Negative
Positive
Brand of wax used: Depileve cream
Area waxed (select if/where appropriate):
Full leg
Bikini line
Underarm
Half Leg
Version 1
Area tested: Wrist
Forearm
Lip
Chin
Date of test: 1/12/10
Method used (select where appropriate):
Hot wax
Cool wax
Details of treatment:
(to include products used)
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Client feedback:
After/Home care advice:
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Learner’s Signature…………………………………
Client’s Signature………………………………………………...
Version 1