Waxing Consent Form

Name

First NameLast Name

Birthdate

Date

Phone Number

Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

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Instagram Handle

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How did you hear about Mode Beauty NYC?

Will you be using a voucher or gift certificate?

When was your last wax?

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the area to be waxed in past 48-72 hours?

Are you using Retin-a, Renova (an oral form of Retin-a), Vitamin A serums or other retinoids in the area to be waxed?

Are you using or have you used Accutane in the past 6 months?

Are you using any other skin thinning products and/or drugs?

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

Do you use a tanning bed?

Are you diabetic?

Are you taking any hair growth supplements?

Do you have any tendencies for:

Please check if pregnant or nursing?

List any allergies:

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

What skin products do you regularly use on your skin?

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

Please list any other illness/condition you are currently being treated for by a medical professional

I have been advised that the services provided provided to me by this salon could have unfavorable results including, but not limited to: allergic reaction, irritation, burning, redness, soreness, ect. I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services. I understand that Mode Beauty NYC does not recommend skin care services for customers using Retin-A, Accutane and products contacting alpha hydroxyl or any other skin thinning treatments. I hereby confirm that I am not using any medications that may cause or contribute to such injury/reaction, and I will advise my esthetician should I use any such medications in the future. I understand there are often inherent risks associated with skin care services, and I agree that as a condition of providing these services on an on going basis, I will not hold Mode Beauty NYC and Esthetician liable.

Initial Here

PHOTOGRAPHY CONSENT

I grant my permission to be photographed and/or video recorded by my treatment provider in order to keep a thorough record of my treatment progress and to promote the skincare services of this facility and my treatment provider. I understand that the images and/or recordings may be used in print and/or online publications, presentations, websites, and social media. I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use. I also understand that the images may be retouched as seen fit by my treatment provider. I consent to these terms on the condition that I will be made aware at the time of any and all photography/recordings, and none shall be taken without my knowledge.

Signature

Date

Signature Of Parent Or Guardian If Under Age 18