Waxing Consent Form
Appointment Date
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Name
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List full name and number of emergency contact.
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Have you ever had an adverse reaction to a waxing service?
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No
Yes
If yes, please explain:
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Type N/A if NO was selected.
Are you using Retin-A, Renova, or Accutane (an oral form of Retin-A)?
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No
Yes
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the last 72 hours?
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No
Yes
Do you regularly use a tanning bed, sunbathe, or plan to do so soon?
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No
Yes
Are you diabetic?
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No
Yes
Do you form thick or raised scarring (keloids) from cuts or burns?
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No
Yes
Are you prone to any of the following?
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None
Ingrown Hairs
Bumps
Scarring
Hyperpigmentation
Allergies
Bruising
If yes, please explain further:
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Type N/A if NONE was checked.
Do you have any body piercings?
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No
Yes
Have you been under the care of a dermatologist or any other medical professional in the last year?
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No
Yes
If yes, please explain:
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Type N/A if NO was selected.
List any medications including prescriptions, over-the-counter or supplements (multi-vitamins, herbal, etc.) you are taking:
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I fully understand that waxing does have possible side effects such as skin removal, allergies, redness, swelling, tenderness, etc. If I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform my waxing procedure(s). I hold the esthetician, B. Miona, and the institution, Miona Naturals LLC, harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I understand the post-treatment home care instructions will be available by email after my treatment is completed. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home/post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand the procedure and accept the risks. I do not hold the esthetician, B. Miona, and the institution, Miona Naturals LLC, responsible for any of my conditions that were present, but not disclosed at the time of this service, which may be affected by the treatment performed today. I understand rude or offensive behavior and language is NOT tolerated at anytime and that the esthetician, B. Miona, and the institution, Miona Naturals LLC, reserves the right to refuse service at any time.
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Yes
I consent to Miona Naturals: Esthetics + Spa to take photos and/or videos of me immediately prior to, during and/or after my treatment. I authorize Miona Naturals: Esthetics + Spa to copyright, use and publish these photos/videos. I consent to Miona Naturals: Esthetics + Spa using such photos and/or videos of me with or without my name and for education, social media, advertising and web content.
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No
Yes
Client/Parent Signature
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Esthetician Name
Date
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Month
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Date
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