Waxing Consultation Cryo Solihull Name(Required) First Last Address(Required) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email(Required) Phone(Required)Occupation GP Surgery Do you have any of the following?(Required) Ingrowing Hairs Any breakouts in the area being waxed Bumps Scarring Eczema/Psoriasis Bruising Diabetes Moles Oedema Phlebitis Hypersensitive Skin Epilepsy Any Scar tissue under 3 months old? Varicose Veins Cancer None of the above If you have ticked yes to any of the above - Please provide further information When did you last shave or trim the hair or have a wax in the area to be waxed? Are you currently using or taking?(Required) Accutane/isotretinoin Retin-A or Glycolic Acid Using Scrubs or Peels Resorclnol Alpha Hydroxy Acid Poor fluid or blood circulation None of the above If you have ticked yes to any of the above please provide further information Have you ever had an adverse reaction to hair removal?(Required) Yes No If you have ticked yes to the above question please give further details Do you have? If you have ticked any of these treatment cannot be carried out.(Required) Herpes virus MRSA / Straph None of the above Have you at any stage in your life had skin cancer, cold sores, or skin injections in the area being waxed?(Required) Yes No If you have ticked yes to any of the above please give further details Do you have any medicalconditions? If yes please provide further details Are you taking any medication? If yes please state what it is taken for Have you sun bathed in the last 24 hours? All sun bathing/beds must be avoided before and after a waxing treatment - If the answer is yes we cannot carry out this treatment Are you pregnant? Or could be pregnant? Please note waxing treatments cannot be carried out under 12 weeks or if you are having a high risk pregnancy(Required) Yes No Could be Please note our cancellation policy is 48 hours - less than 48 hours full cost of the appointment will be charged(Required) I agree to the privacy policy. And give consent to Cryo Solihull to store my details under GPDR compliance. Δ
