Waxing Consent Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Age

Please select which service(s) you wish to book.

Is this your first time getting this service done? If no, how long has it been since you've received this treatment?

Have you used any exfoliating products such as (but not limited to) glycolic, salicylic, lactic acid or benzoyl peroxide in the past 48-72 hours?

Have you used Retin-A, Renova, or Accutane within the past year? If so, when? (Please note, no waxing or lamination services can be performed if you have taken Accutane within the last year. Stop use of Retin A 3-4 days before any facial waxing or Lamination.)

Have you had Botox in the last 48 hrs?

Do you use tanning beds and/or are exposed to the sun on a regular basis? (Please note, if you have a sunburn you can NOT get a wax or lamination over the area.)

Are you currently taking any medications? If so, please list.

Please note that certain medications and herbal supplements can thin the skin and cause lifting and/or adverse reactions during waxing and brow laminaton.

Have you been treated for cancer within the last year? If yes, what types of therapies were used?

Please list any illness/medical conditions.

Do you have a heart condition?

Do you have epilepsy?

Please note that if you have a heart condition or epilepy, no High Frequency treatments can be performed on you.

Are you pregnant or breast feeding? If yes, consult your doctor before services such as: Brow Lamination, Tinting and Lash Lift.

Do you use a lash growth serum? If yes, please stop use at least 3 days before a Lash Lift.

Do you have any allergies? If so, please list.

Please note that waxing, brow lamination, brow tinting, lash lifts and skin treatments can have certain side effects such as (but not limited to) skin removal, redness, swelling, tenderness, hair damage etc.

I have read the information above and if I have any concerns I will address them with my Esthetician. I am aware of the contraindications for the service(s). I give permission to my Esthetician to perform the service(s) discussed and will not hold her or her business liable for any adverse reaction that may occur from the treatment. I agree to adhere to all safety post care recomendations including no peels, tanning, swimming, spas, hot tubs, etc. for 24-48 hours after my service. I am responsible for following all after care instructions recommended by my Esthetician. I understand that my Esthetician will take every precaution to minimize or eliminate adverse reactions.

Signature

Parent signature if under 18

Date