Waxing Consent Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Are you using Retin-A (tretinoin) or any of the following: (Adapalene, Isotrentinoin, Clindamycin/Trentinoin, Tazarotene, Acitretin, Bexarotene, Alitretinoin, Fluocinolone/Hydroquinone/Tretinoin? **If yes, your technician will not remove hair from that area and a 3 inch surrounding area**

YesNo

Are you taking Accutane? **If yes, your technician will not be able to perform any hair removal services**

YesNo

Are you currently undergoing any chemical peels, dermabrasion, facial surgery or laser treatments? **If yes, you will need a doctors release that there has been enough time since treatment in order to service the affected area**

YesNo

Are you using any over the counter products that contain Glycolic Acid, Alpha Hydroxy Acid, Benzoic Acid, Benzoyl Peroxide, or Salicylic Acid for wrinkles or blemishes? **If yes, you must be free of these products for 72 hours before hair removal**

YesNo

Are you under a physicians or dermatologists care?

YesNo

If yes, for what medical condition?

Are you taking any medications that cause thinning of skin such as blood thinners, and corticosteroids? **If yes, your technician will perform a patch test to see if hair removal services are appropriate**

YesNo

Are you taking any medications that may cause water retention? (Some hormone drugs containing estrogen, blood pressure lowering medication, steroids and antidepressants may cause water retention.)

YesNo

Are you pregnant or expecting a menstrual cycle?

Expecting cyclePregnantNeither

*Water retention can cause temporary puffiness or reddening, especially on the facial/sinus areas. Your technician will take a precautionary thumb print test to see if this may occur, and if he/she feel it may, they will apply a cold wet compress over the finipil antiseptic after the hair removal for 60 seconds.

In order for your technician to perform an efficient hair removal you must have at least 7 to 10 days of hair growth from your 1st appointment and 3 to 4 weeks of hair growth for your 2nd appointment.

I confirm to the best of my knowledge that the answers I have given are correct and I have not withheld any information:

CLIENT NOTES

Signature

Date