SkinU-RN Waxing Consent Form

SkinU-RN General Consent

This form is valid for up to one year from the date of the client's signature once it has been completed.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Do you have any open skin lesions?*

YesNo
Please select the service(s) you are receiving*

Facial ServicesWaxing ServicesBoth
Have you received a facial treatment within the last 6 months?*

YesNoN/A - Receiving Waxing Services Only
If you answered yes, when was your last facial treatment

MonthDayYear
Date
Which of the following best describes your skin type?*

Creamy Complexion(Always burn easily, never tans)Light Complexion(Always burns, tans slightly)Light/Matte Complexion(Burns moderately, tans gradually)Matte Complexion(Seldom burns, always tans well)Brown Complexion(Rarely burns, deep tan)Dark Brown Complexion(Rarely burns, deeply pigmented)
Your health is important to us. Please contact SkinU-RN at 901-501-6717 to reschedule your appointment. We ask that you have medical clearance from your doctor before any services can be provided.
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*

YesNo
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?*
If No, put N/A
Are you using any other skin thinning products and/or drugs that thin the blood?*

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

YesNo
Are you currently taking any medications? If so, please list. For Female clients this includes oral contraceptives.*
If No, put N/A
Have you been treated for cancer? If yes, when and what types of therapies were used?*
If No, put N/A
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.*
Do you have any of the following? Select all that apply.*

PiercingsTattoosPermanent CosmeticsPlastic SurgeryDiet RestrictionsPacemakerMetal ImplantsNone of the aboveAll of the above
Where?
Female Clients Only - When was your last menstrual cycle?
Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.
Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to SkinU-RN to perform the waxing procedure we have discussed and will hold her 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 prescription drugs or products I am currently ingesting or using topically. I understand SkinU-RN 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 SkinU-RN 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 SkinU-RN 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 SkinU-RN 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 during my appointment.
Client Name (Printed)*
Client Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

SkinU-RN General Consent