Facial Waxing/ Lash & Brow Tinting Waiver

1

Full Name* This field is required.

2

I understand and certify that I am 18 years of age or older.* This field is required.

I understand I must be 18 in order to receive services.

3

1. Have you previously had facial waxing?* This field is required.

Yes

No

4

2. Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?* This field is required.

Yes

No

5

3. Are you using Retinol, Retin-a, Renova or Accutane (an oral form of Retin-a)?* This field is required.

Yes

No

6

4. If YES to Retinol (or similar) or Accutane, please list product and the date of last use. Retinol should be discontinued for 14 days prior to wax. Accutane should be discontinued for 12 months.

7

5. Are you using any other skin thinning products and/or drugs?* This field is required.

Yes

No

8

6. If using skin thinning products or drugs, explain below.

9

7. Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?* This field is required.

Yes

No

10

8. Do you use a tanning bed?* This field is required.

Yes

No

11

9. Are you diabetic?* This field is required.

Yes

No

12

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

13

11. What skin products do you regularly use on your skin?* This field is required.

14

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

15

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

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14. Have you ever had any adverse reactions to tint or dyes on the eyebrows/face or scalp?* This field is required.

Yes

No

17

16. Have you ever had any adverse reactions to wax on the eyebrows/face or body?* This field is required.

Yes

No

18

15. If YES to adverse reactions from tint, dyes, or waxing, explain below.

19

17. If YES to previous question, explain below.

20

I understand that if I am breastfeeding, getting any chemical treatment (Including dyes) to my eyelashes, eyebrows or face is at my own risk and I should clarify with my doctor about the safety of these procedures before booking.* This field is required.

I understand

21

Signature* This field is required.

Clear

22

Parental Cosign here

I agree to use electronic records and signatures.

23

Signature

Clear

24

I grant Jamee Mittell Esthetics Studio permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes and eyelashes in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials.

I consent

I do not consent

25

I have read the previous information and if I have any concerns, I will address these with my esthetician. I give permission to my esthetician to perform the waxing procedure we have discussed and will hold her and her staff 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 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 product/post- treatment care, I will consult my esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the previous paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, nor Jamee Mittell Esthetics Studio responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Clear