Waxing Consent Form
Customer Name
First Name
Last Name
Customer Email
example@example.com
Customer Phone Number
Please enter a valid phone number.
Customer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Age
Gender
Please Select
Male
Female
Please answer the health and skin checker for the safety of the procedure:
Yes
No
Remarks
Have you done any waxing before?
Are you currently taking any medications?
Have you had any skin thinning treatments before?
Are you Pregnant? (Female)
When is your next menstrual cycle? (Female)
Do you have sensitive skin?
Do you have skin allergies?
Do you bruise easily?
Are you prone to scarring and hyperpigmentation?
Are you currently using any cosmetic products that may contain the following substance? Kindly check if yes and if no, leave it blank.
Accutane Retin-A or retinoids
Renova
Differin
AHA
BHA
Glycolic Acid
Waiver Consent
I am providing my consent to complete the procedure I am requesting for I am duly aware of the side effects of waxing to my skin during or after the procedure such as:skin redness, swelling, skin irritation, bruises, or bumps. I acknowledge and completed health and skin checker, efficiency, and accuracy. I was instructed and enlightened that some cosmetic additives or chemical substances itemized were hazardous when coupled with waxing and may most likely cause disappointing results and side effects to my skin area. I hereby affirm that I have read and fully understand the above, am over eighteen years of age and am legally liable for my own decisions/actions. By signing below, it means that I agreed to the terms indicated in this document.
Customer Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: