Waxing Consent Form

Name*

First NameLast Name

Birthdate*

Date

Phone Number*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

Mode Beauty NYC occasionally sends out emails to announce special events, seasonal promotions, new products and treatment offerings. You can opt out any time by clicking the unsubscribe button in the emails.

Instagram Handle

Share your Instagram handle, and I’ll follow your account so we can stay connected and keep up witfh each other!

How did you hear about Mode Beauty NYC?

Will you be using a voucher or gift certificate?*

YesNo

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?*

YesNo

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

YesNo

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

YesNo

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

YesNo

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

YesNo

Do you use a tanning bed?*

YesNo

Are you diabetic?*

YesNo

Are you taking any hair growth supplements?*

YesNo

Do you have any tendencies for:

Please check if pregnant or nursing?

Yes

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*

I acknowledge that I must adhere to Mode Beauty NYC’s cancellation and late policies. I understand that appointments should be canceled with at least 24 hours notice to allow availability for other clients.

I also understand that if I arrive more than 10 minutes late, my appointment may need to be adjusted, rescheduled, or canceled based on the remaining time available.

Initial Here*

At Mode Beauty NYC, your satisfaction is my top priority. If, for any reason, you’re not fully satisfied with your service or product, I kindly ask that you adhere to the following guidelines:

If you have any concerns about a service or product, please reach out to me directly within 24 hours of your appointment or purchase.

Before posting a review or sharing your concerns on social media, I kindly request that you allow me the opportunity to address and resolve the issue. My goal is to ensure you leave feeling confident and cared for.

If necessary, I may request that you come in for an in-person assessment. This will allow me to better understand your concerns and determine the best course of action to address them.

Please note that all services and packages are non-refundable. However, I am committed to doing everything possible to make your experience positive and meet your expectations.

Exchanges for products may be available within 24 hours of purchase at my discretion. Please provide details about your concerns to help me better understand how to assist you.

By initialing here, I acknowledge and agree to these terms

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.

I consent to my photos being used for marketing, social media and other sources(only non sensitive areas such as underarms, legs, arms, etc.)I DO NOT consent to my photos being used for marketing, social media and other sources

Signature*

Date*

Date

Signature Of Parent Or Guardian If Under Age 18