Waxing

Name*

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Today's Date

Date

Birthday

Date

List any medications, supplements, or herbal remedies you currently take:

Do you use Accutane, Retin-A, Renova, Adapalene Hydroxyl Acid or any other Retinol/vitamin A derivative products? ***No waxing if you’ve used Retin-A in the past 2 weeks!!!*******

YesNo

Do you have any allergies or product sensitivities?:

Please check all that apply.*

Have you been waxed before?

YesNo

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive waxing services/and/or brow tinting.
2) I understand the risks associated with massage therapy, facials, and waxing include, but are not limited to:
• Superficial bruising or redness
• Exacerbation of undiscovered injury

I, therefore, release Fresh Complexions llc and Rita Krause from all liability concerning any injuries that may occur during waxing.
I understand the importance of informing my aesthetician of all medical
conditions and medications I am taking, and to let them know about any changes to these. I understand that there may be additional risks based on my physical condition.
I understand that it is my responsibility to inform my aesthetician of any
discomfort I may feel during the session so he/she may adjust accordingly. I understand that I or the aesthetician may terminate the session at any time. I have been given a chance to ask questions about the session and my questions have been answered.

Signature*