Advanced Treatments/Waxing Form

Neblibana

Advanced Treatments/Waxing Consent Form
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
If minor, Parent/Guardian Name is required

Parent’s First NameParent’s Last Name
Phone Number*

Area CodePhone Number
Email Address
example@example.com
Address

Street Address

Apartment or Suite Number

CityState

Zip Code
Advanced Treatments Informed Consent

Thoroughly read this informed consent form. Select whether you agree with each statement and sign and date the bottom. If you have any questions, discuss them with your skin care or clinical professional.
I hereby authorize Neblibana LLC and its associates to perform one or more of the following procedures:*

Resurfacing Treatment (35% glycolic)Advanced Resurfacing Treatment (50% glycolic)Dermaplane TreatmentMicroneedlingRezenerate NanoneedlingWaxing
I acknowledge that these Procedures have been explained to me and I completely understand the nature and consequences of the Procedures.*

I agree with the statementI disagree with the statement
I acknowledge that I have not used or taken Accutane, Retin-A, Renova within the past two days.*

I agree with the statementI disagree with the statement
I acknowledge that I do not have any conditions that would prevent my consent or require a doctor’s consent to have these Procedures. Additionally, check any of the following conditions that apply:*

Active sunburn within 24 hoursActive herpes, cold sores, fever blistersPregnancy, breastfeedingRecent laser procedures or tattoosRecent chemical peels, microdermabrassionRecent waxingFever, cold, flu or COVID-19 in the last 14 daysInteraction with anyone diagnosed with COVID-19 in the last 14 daysI do not have any of the above
I acknowledge the possibility of allergic reaction, and that neither Neblibana LLC or its associates are responsible for such a reaction or any medical care that may be necessary in the unlikely event of such reaction.*

I agree with the statementI disagree with the statement
I acknowledge that during the Procedures, I may experience some discomfort, swelling, redness and the affected area may be dry and rough for a short time after the Procedures.*

I agree with the statementI disagree with the statement
I will not pick, peel, or use an abrasive product on the treated skin area for several days following the Procedures since these actions could potentially lead to an infection and/or pigment changes in the area.*

I agree with the statementI disagree with the statement
I understand that I should avoid direct sun exposure and/or tanning booths immediately following the Procedure, and that I must protect my skin with sunscreen SPF 15 or above and UVA, UVB protection.*

I agree with the statementI disagree with the statement
I ACKNOWLEDGE THAT THESE PROCEDURES ARE PURELY ELECTIVE AND THAT NO GUARANTEES HAVE BEEN MADE TO ME AS TO THE RESULTS OF THE PROCEDURES.*

I agree with the statementI disagree with the statement
Waxing Informed Consent
Are you using any oral or topical acne medications (Retin-a, Renova or Accutane)?

YesNo
Are you currently taking any oral antibiotics?

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

YesNo
Do you have any open wounds or abrasions in the area to be waxed?

YesNo
Do you consider yourself to be sensitive to waxing or have you ever experienced any unusual reactions post waxing?

YesNo
Are you on or close to the beginning of your menstruation cycle?

YesNoNot Applicable
Are you aware of post waxing precautions to ensure proper results following a waxing service?

YesNo
Any known allergies?

ShellfishIodineAspirinTree NutsSunscreenLatexFragranceEssential OilsDairyPollenNoneOther
Post-Waxing Care

To avoid irritation following waxing avoid the following for approximately 6 hours:
1. Exposure to the sun or extreme heat on the waxed area (and up to 48 hours)
2. Exposure to chlorinated water on the waxed area
3. Application of fragranced lotions, cosmetics or deodorants on the waxed area
4. Activities that induce excessive perspiration in the waxed area
5. Application of products designed to exfoliate physically (scrubs) or chemically (acids) on the waxed area
If irritation occurs, the following may be helpful in reducing any bumping or redness:
1. Apply cold compresses, soaked in water and 3 to 5 drops of tea tree oil directly to the area of irritation
2. Apply a small amount of hydrocortisone cream to the area of irritation
I have read the above consent and fully understand the same and do authorize Neblibana LLC and/or it's associates to perform these Procedures on me. I acknowledge that the information provided is accurate and up-to-date.
Client Signature*

Clear
If minor, Parent/Guardian signature is required

Clear
Date Signed*

MonthDayYear
Date
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Neblibana

Advanced Treatments Informed Consent

Waxing Informed Consent