HAIR REMOVAL

CLIENT DATA FORM

PAGE 1 OF 2

Date: _______________ Birthday (Day/Month) ______ / ______

Name: _______________________________________________________________________
Address: ___________________________ City/State: ________________ Zip: __________
Primary Phone: _____________________ Secondary Phone: ______________________
Email: _________________________________________________________________________

How did you hear about us: ___________________________________________________

Would you like to be informed of upcoming promotions via email? YES NO

TREATMENT GOALS AND SENSITIVITIES

1.) What areas are being treated today? (Full leg, half leg, bikini, Brazilian, etc.)
___________________________________________________________________________
2.) Are you currently on topical medication such as Retin-A or Differin?
YES NO If yes, please list: _______________________________________________
3.) Have you used Accutane in the last six months? YES NO
4.) Have you undergone any of the following treatments:
Laser, medical dermabrasion, or chemical peeling? YES NO
If yes, please list dates: ___________________________________________________
5.) Any skin sensitivities we should be acknowledge? YES NO
If yes, please explain: ____________________________________________________

MEDICAL SCREENING AND CONTRAINDICATIONS

Have you been diagnosed, or are you experiencing symptoms of the following
conditions?

Heart Irregularity YES NO Psychiatric Conditions YES NO

High or Low Blood Pressure YES NO Recent Operations YES NO
Diabetes YES NO Trapped/Pinched Nerve YES NO
Medical Oedema YES NO Inflamed Nerve YES NO
Osteoporosis YES NO Severe Varicose Veins YES NO

Fever YES NO Scar Tissue YES NO

Infectious Diseases YES NO Sunburn YES NO
Influence of Drugs or Alcohol YES NO Self Tan YES NO
Infectious Skin Disease YES NO Heat Rash YES NO
Undiagnosed Lumps/Bumps YES NO Hairy Moles YES NO
Localized Swelling YES NO Hormonal Implants YES NO
Inflammation YES NO Recent Fractures YES NO
Cuts YES NO Neuralgia YES NO
Bruises YES NO Hypersensitive Skin YES NO

4703 West Lovers Lane, Dallas 75209 (214) 352-8800 www.luxuryonlovers.com

 HAIR REMOVAL
CLIENT DATA FORM
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MEDICAL SCREENING AND CONTRAINDICATIONS (CONT.)

Abrasions YES NO Loss of Skin Sensation YES NO
Bells Palsy YES NO Vascular Skin YES NO
Abnormal Hair Growth YES NO

Please list any allergies: ___________________________________________________________

_______________________________________________________________________________

Client Acknowledgement
I, the undersigned, understand and agree to comply with all instructions. I have
been properly instructed prior to my hair removal session. I am using these
services at my own risk. I hereby authorize and direct employees or agents of
Luxury on Lovers to perform such procedures as may be deemed necessary or
advisable, and have provided them with the above information required. I
acknowledge that the results of professional hair removal do vary, and that no
guarantees of specific results are offered or implied. I have read the contents of
this consent form carefully and state that I am not aware of any medical
condition or other reason that would prohibit me from engaging in hair removal
treatments.

I hereby relieve this establishment and their employees; and hold them
harmless, from any liability involved in the use of the hair removal process.
Luxury on Lovers and their agents or employees are not liable for any injury to
person or property; or the loss or theft of any personal property.

Client Signature: _________________________________________ Date: ____________

Technician Signature: ____________________________________ Date: ____________

Client Information:

4703 West Lovers Lane, Dallas, TX 75209 (214) 352-8800 www.luxuryonlovers.com