WAXING

WAXING

CONSENT FORM
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

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MEDICAL/HISTORY DATA
PsoriasisDiabetesEczemaHistory of skin disease or skin sensitivityOther
YesNo
Are you currently taking any medications? If yes, please list them below:
AUTHORIZATION

I give permission to Sophia Cooper to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I understand waxing does have certain side effects and risks such as skin removal, redness, swelling, tenderness, etc. If I have any concerns I will address those with my aesthetician. I understand my aesthetician will take every precaution to minimize or eliminate negative reaction as much as possible. I have not used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 Hours nor am I using a Retin-A,Renova, or Accutane. I am not using any other thinning products and/or drugs that would increase risks of waxing.
I have read and understand the contents of each paragraph above. I acknowledge this is a contract and that I have received no warranties or guarantees with respect to the benefits to be realized from, or consequences of, the aforementioned procedure(s). I further acknowledge that at the time of signing this consent to this procedure(s), I was of sound mind and capable of making independent decisions for myself.
Signature of the Patient*

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Date*

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WAXING

MEDICAL/HISTORY DATA

AUTHORIZATION