BEAUTY KULTURE STUDIO & ACADEMY
WAX TREATMENT CONSENT FORM
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How often do you have waxing done?
*
Have you ever had a reaction to a waxing service? YES or NO - If yes, please describe:
*
Do you have any tendencies to:
*
Ingrown Hair(s)
Scarring
Bumps
Hyperpigmentation
Bruising
NONE OF THE ABOVE
Are you allergic to anything?
*
Yes
No
If yes, please describe your allergies:
*
Have you received Botox treatments in the last 72 hours?
*
Yes
No
Have you been or will you be in the sun and/or tanning bed within 24 hours of this treatment?
*
Yes
No
Are you using or taking:
*
Accutane or Tetracycline
Retinoids such as Retin-A, Renova or Diferin
AHA/Alpha-Hydroxy Acid
BHA/Beta-Hydroxy Acid
Glycolic Acid
NONE OF THE ABOVE
Any other medications ?
Are you currently pregnant?
*
Yes
No
Do you have Diabetes, Phlebitis or any skin irritations?
*
Yes
No
Signature
*
*
SUBMIT
Should be Empty: