Unit 816 – Remove Hair Using Sugaring
Treatment Evidence Form
College Name:
College Number:
Learner Name:
Learner Number:
Date:
Client Name:
Address:
Profession:
Tel. No: Day
Eve
PERSONAL DETAILS
Age group: Under 20
20–30
30–40
Lifestyle: Active
Sedentary
Last visit to the doctor:
GP Address:
No. Of children (if applicable):
Date of last period (if applicable):
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
Bell’s Palsy
CONTRAINDICATIONS THAT RESTRICT TREATMENT
Fever
Infectious or contagious diseases
Under the influence of recreational drugs or
alcohol
Any known allergies
Infectious skin diseases and disorders
Undiagnosed lumps and bumps
Localised swelling
Inflammation
Cuts
Bruises
Abrasions
Scar tissue (2 years for major operation and 6
months for a small scar)
Patch Test:
Negative
Positive
Brand of sugar paste used:
Method used:
Sugar paste (hand)
(select if/where appropriate)
Sunburn
Self tan
Heat rash
Hormonal implants
Recent fractures (minimum 3 months)
Neuralgia
Hypersensitive skin
Loss of skin sensation
Vascular skin
Hairy moles
Varicose veins
48 hours after sun tanning
Abnormal hair growth
Area tested:
Date of test:
Strip sugar
Area sugared (select if/where appropriate):
Full leg
Underarm
Upper lip
Unit 816 Remove Hair Using sugaring
Half Leg
Forearm
Chin
Bikini line
Eyebrows
Other
Treatment Evidence Form
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Treatment details:
(to include products used)
Client feedback:
After/Home care advice given:
Client’s Signature………………………………………………...
Learner’s Signature. ……………………………….……………
Unit 816 Remove Hair Using sugaring
Treatment Evidence Form
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Skin Sensitivity/Patch Test
Client Information
Please read carefully and only sign if you are in full agreement with its contents
I ------------------------------------------------- confirm that I have received the required patch test (s) 24-48 hours
prior to sugaring treatment and confirm that I am willing to proceed.
You should note that if the learner is unable to explain to you the treatment contra-actions and
contraindications or is unsure of anything that may apply to a specific condition then they should not treat you
without asking you to consult with your GP or Consultant.
It is your responsibility and not that of the learner to consult your GP or Consultant.
I hereby indemnify the learner against any adverse reaction sustained as a result of the treatment
Client Signature........................................
Date.......................................
Learner Signature.....................................
Date........................................
Unit 816 Remove Hair Using sugaring
Treatment Evidence Form
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