WAXING CONSENT FORM

WAXING CONSENT FORM
Client Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Date

MonthDayYear
Date
Service(s) booked:
HAVE YOU TAKEN ACCUTANE WITH THE PAST YEAR?
ARE YOU USING RETIN-A, DIFFERIN, OR RENOVA?
ARE YOU TAKING ANY MEDICATIONS THAT MAKE YOU PHOTOSENSITIVE?
DO YOU CURRENTLY HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONS THAT COULD COMPROMISE YOUR SKIN AND/OR SERVICES BEING OFFERED
**PLEASE READ THE FOLLOWING WARNINGS
IF YOU ARE USING ANY OF THE FOLLOWING MEDICATIONS, YOU CAN NOT BE WAXED TODAY:
- ACCUTANE
- ADAPALENE
- ISOTRETINOIN
- RETIN-A
- RENOVA
- ALUSTRA
- AVITA
- TAZAROTENE
- TRETINOIN
- AVAGE
- DIFFERIN
YOU MAY EXPERIENCE SKIN SENSITIVITY/THINNING, WHICH CAN RESULT IN SKIN LIFTING, FROM THE FOLLOWING:
- SUNBURNED SKIN
- RETINOL
- CERTAIN MEDICAL CONDITIONS
- PREGNANCY
- ANTIBIOTICS
- OTHER MEDICATIONS NOT LISTED
- MENSTRUATION
CONSENT AND SIGNATURE:
I UNDERSTAND THAT IF I BEGIN USE, OR ARE CURRENTLY USING, ANY OF THE PRODUCTS LISTED IN THE ABOVE WARNING AND DO NOT INFORM THE ESTHETICIAN PRIOR TO CURRENT OR FUTURE TREATMENTS, I ACCEPT FULL RESPONSIBILITY FOR ANY ADVERSE REACTIONS.

I UNDERSTAND THAT WAXING MAY CAUSE SOME REDNESS, BUMPS, SORENESS, AND/OR ITCHING.
CLIENT SIGNATURE (18 & OLDER):
Signature
PARENT/GUARDIAN CONSENT (UNDER 18 YRS OF AGE):
Parent/Guardian Name

First NameLast Name
SIGNATURE OF PARENT/GUARDIAN (IF UNDER 18):
Signature
**IF ANY PROBLEMS OR ISSUES OCCUR POST WAXING, PLEASE CONTACT US IMMEDIATELY!
Should be Empty:

WAXING CONSENT FORM

**PLEASE READ THE FOLLOWING WARNINGS

CONSENT AND SIGNATURE:

CLIENT SIGNATURE (18 & OLDER):

PARENT/GUARDIAN CONSENT (UNDER 18 YRS OF AGE):

SIGNATURE OF PARENT/GUARDIAN (IF UNDER 18):

**IF ANY PROBLEMS OR ISSUES OCCUR POST WAXING, PLEASE CONTACT US IMMEDIATELY!