Waxing Consent Form

1

Name

First Name

Last Name

2

Email

example@example.com

3

Phone Number

Area Code

Phone Number

4

Age?

5

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

Yes

No

6

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

7

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

Yes

No

8

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

Yes

No

9

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

10

Do you have anyof the following tendencies: Ingrowns, Scarring, Bumps, Hyperpigmentation or Bruising. If yes, which ones?

11

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

12

Do you have any open skin lesions?

Yes

No

13

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

14

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

I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

15

Signature

Clear

16

Date?