Waxing Consent Form

JUSTIFIED SKIN ESTHETICS

Waxing Consultation Form
About you
Name

First NameLast NameSuffix
Age?
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Have you ever been waxed before?

YesNo
Health Questionnaire
Are you under a dermatologist's care?*

YesNo
Have you had any health problems in the past or currently?*

EpilepsyDiabetesCancerBlood pressureHormonal imbalance / PCOSNerve disorderVaricose veinsNerve disorderN/A
Have you taken any of these medications in the last 6 months (select all that apply)

Isotretinoin / RetinAAdapalene (Differin)RenovaHydroquinoneHydrocortisoneAntibioticsTazoracAccutaneN/A
Are you using any other skin thinning products and/or blood thinning drugs?

YesNo
Are you allergic to any topical products? If yes, please list (If none, put N/A)*
Do you have any open skin lesions?

YesNo
Are you currently taking any medications? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any illness/conditions which you are currently being treated for by a medical professional.
Do you have any allergies? If so, please list.
Reproductive Questions
Are you currently on or due for your menstrual cycle?*

YesNoN/A
Are you pregnant?*

YesNo
Wax Consultation Check-off
Are you currently undergoing any of the following treatments (select all that apply)*

Chemical peelLaser therapyFacial surgeryDermabrasionN/A
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*

YesNo
Were you overexposed to the sun in the last 48 hours?*

YesNo
Do you use tanning beds and/or are exposed to the sun on a regular basis?*

YesNo
Do you mind if images or videos are taken during your service? These images are in your file to track progress. There is a chance the images could be used for marketing also.
What genre of music would you like to listen to during your service?
Sign and Date
Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and have given an accurate account of the questions 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 harmless from any liability that may result from this treatment. 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. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
Signature*

Clear
Please verify that you are human*
Should be Empty:

JUSTIFIED SKIN ESTHETICS

About you

Health Questionnaire

Reproductive Questions

Wax Consultation Check-off

Sign and Date