Waxing Consent Form

Name

First NameLast Name

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?

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.

Do you have any allergies? If so, please list.

Please note that waxing can have certain side effects such as skin lifting, 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 Megan Gardner. I give permission to Megan Gardner 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 physical or sexual activity, no pools or hot tubs, for 24 hours. No exfoliating or tight clothes for 48-72 hours. I understand that Megan Gardner will take every precaution to minimize or eliminate negative reactions as much as possible.

Signature

Date