I First Name Last Name (print name), give consent to the service provider at Healing Elements Day Spa to perform the following wax services: I have not used a scrub, Retin-A, Retinol OTC, take home micro-dermabrasion, glycolic peels, other peels, exfoliated or tanned in the last 72 hours. (initial). I have been off of Accutane for a least twelve (12) months. (initial.)Some possible side effects include redness, swelling, pimples, but these are temporary and generally fade within 72 hours. (initial)I understand that with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. (initial.)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. If I don't follow these protocols I'm aware that Healing Elements in not liable for issues after (initial.)I will call to inform my service provider of any complications or concerns I may have as soon as they occur. (initial.)If at anytime things change I will let the service staff know before getting future waxing services. (initial.)
My signature acknowledges that I have read and agree to receive the following treatments or series of treatments listed above and that I adhere to all the above statements I have initialed.