Name
*
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Birth date
*
/
Month
/
Day
Year
Date
How did you hear about us?
*
Google
Social media
Referral
Other
Have you used any Retin-A or retinoids in the past 7 days?
*
Yes
No
Have you been on Accutane in the past year?
*
Yes
No
Do you currently use any products on your face containing retinol, glycolic acid, salicylic acid or benzoyl peroxide? If yes, please explain.
*
Are you using any other skin thinning products and/or drugs that thin the blood?
*
Yes
No
Are you diabetic?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
*
Yes
No
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?
*
Do you have any allergies? If so, please list.
*
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
*
Date
*
-
Month
-
Day
Year
Date
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