Waxing Client Information and Consent

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Have you used any Alpha Hydroxy Acids (AHAs) or glycolic acid products in the past 48-72 hours?

YesNo

Are you using Retin-A, Renova or Accutane (an oral form of Retin-A)?

YesNo

Are you using any other skin thinning products and/or drugs?

YesNo

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

YesNo

Do you use a tanning bed?

YesNo

Are you diabetic?

YesNo

Are you allergic/sensitive to honey/bee's wax?

YesNo

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

What skin care products do you regularly use?

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

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

Female clients: When is your next menstrual cycle due to begin? (Always allow 5 days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal 2 days before your cycle is due and 2 days after it is completed)

Date

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

I have read the above 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/him and any employee of S3 Spa LLC, DBA Sonoran Serenity Spa 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 prescriptions 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 have read and understand the post treatment home care instructions. 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 the 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 above 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, whose signature appears below, 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.

Client Signature:

Date