Waxing Consent Form
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Questionnaire
Answer the Following Questions
Are you at least 18 years old?
*
Yes
No, I will provide parental consent
Have you ever been waxed before?
*
Yes
No
If you answered yes to the question above, what area(s)? Did you have any reactions?
Do you have sensitive skin?
*
Yes
No
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the last 72 hours?
*
Yes
No
Have you used Retin-A, Accutane, Alustra or Renova in the last 7 days?
*
Yes
No
Are you currently using any skin or blood thinning products?
*
Yes
No
Have you recently tanned using a tanning bed, or are you currently sun burned?
*
Yes to one or more
No
Are you currently taking any medications you think I should be aware of? If so, please list them below:
*
Do you have any current illnesses or conditions diagnosed by a medical professional that you feel I should be aware of? If so, please list them below:
*
Do you have any allergies? If so, please list them below:
*
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Property Liability
Please answer the following questions
I will not share Riri Brow Bar’s address with anyone without consent
*
I agree
I will not damage Riri Brow Bar’s property, if any damage is done I will be fully responsible for damage
*
I agree
I understand that the property is a private property, and I may be asked to leave if necessary at any time
*
I agree
I will hold Riri Brow Bar harmless for any possible injury sustained on the property
*
I agree
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Signature
Please note, waxing can have side effects including skin removal, redness, swelling tenderness, etc. I have read and agree with the above information. I have given an accurate account of all of the questions, if I have any questions or concerns I will address these with my service provider. I understand that Riri Brow Bar will take precaution to minimize and/or eliminate unwanted reactions. I give permission to my service provider to perform the waxing procedure and I will hold her harmless from any liability that may result from this treatment.
*
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