Waxing Consent Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Your Age*

Are you pregnant?*

YesNoN/A

If pregnant, how far along are you?

Haave you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*

YesNo

Have you used Retin-A, Renova, or Accutane within the past year? If so, when?*

Are you using any other skin thinning products and/or drugs that thin the blood?*

YesNo

Do you use tanning beds and/or are exposed to the sun on a regular basis?*

YesNo

Are you currently taking any medications? If so, please list.*

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

Please list any illness/conditions which ou are currently being treated for by a medical professional. *

Do you have any open skin lesions?*

YesNo

Do you have any allergies? If so, please list.*

Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these with my Esthetician(Dorthy). I give permission to my Esthetician(Dorthy) to perform the waxing procedure we have discussed and will hold her or Dorthy's Eyebrow Threading Spa Inc. harmless from any liability that may result from this treatment. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

Signature*

Today's Date

Date