Waxing + Tint Consultation and Consent

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Email*

example@example.com

Birthdate*

Date

How did you hear about us?*

Have you been waxed before? If so, when?*

Have you used Retin-A, Renova, or Accutane within the past year? If so, when?*

Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*

NoYes

Are you using any other skin thinning products and/or drugs that thin the blood?*

NoYes

Do you use tanning beds and/or are exposed to the sun on a regular basis?*

NoYes

Do you have any open skin lesions?*

NoYes

Have you ever used hair color/eyelash tint/eyebrow tint?*

NoYes

Do you have diabetes, lupus, or any auto-immune disease? Yes/No (If yes, describe)*

Have you ever had an allergic reaction to hair color? Yes/No. If so, please explain*

Are you currently taking any medications? If so, please list (including over the counter drugs/herbal supplements):*

What skin products do you regularly use on your skin?*

Have you been treated for cancer? If yes, when and what types of therapies were used?*

Please list any illness/conditions which are currently being treated for by a medical professional. *

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

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. If and when anything changes from the information above, I will inform my esthetician and fill out a new consent form. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
I have read and understand the post-treatment home care instructions on www.bareskinbeautylounge.com . I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.

I am aware and agree that there is a 24 hour cancellation policy. Any appointment cancelled within 24 hours will be charged 50% of the full service amount. No call / no show will be charged 100% of the cancellation fee. The card on file will be charged accordingly.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose name appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

By signing below, I verify that I have read and understand the above statements and agree to them.

Client name (Printed)*

Signature*

Date*

Date

Parent name (printed)

Parent phone number

Parent Signature

Date*

Date

Esthetician: Natalia Kurelic

By applying my electronic signature to this agreement, I agree that my electronic signature is the legally binding equivalent of my handwritten signature on paper. I will not, at any future time, claim that my electronic signature is not legally binding or enforceable. By electronically signing and submitting this agreement, I 1) acknowledge that I have read and fully understand the terms of the agreement; 2) voluntarily agree to be bound by this agreement; and 3) certify that I am 18 years of age or older. My signature applies to all pages of this contract. I understand that I will receive a Portable Document Format (PDF) version of this agreement after it is signed at the email address I have provided. To view the PDF document, I understand that I will need software that enables me to receive and access PDF files such as Adobe Reader software or other software capable of reading a PDF file. In order to print and retain a hard copy of this agreement, I understand that I will also need a printer connected to my computer. I understand that if I wish to sign a hard copy of this agreement instead of an electronic version, I must contact the party that requires my signature on this agreement directly.

The Wax Witch

For clients under 18:

Esthetician: Natalia Kurelic