3141 E Broad St Suite 303 Room 114, Mansfield, TX 76063
(682) 213-0798
lealux.glossgenius.com
Facial Wax Consent Form
Client Details
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone
*
Please enter a valid phone number.
Email
*
example@example.com
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Medical Information
Have you ever had a reaction to a waxing service?
*
Yes
No
If yes, please describe:
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-a, Renova or Accutane (an oral form of Retin-a) in the past 6 months?
*
Yes
No
Are you using any other skin thinning products and/or drugs?
*
Yes
No
Do you have diabetes, phlebitis or any skin irritations?
*
Yes
No
Are you receiving treatment for cancer related illnesses such as chemotherapy or radiation treatment?
*
Yes
No
Have you been or will you be in the sun and/or tanning bed within 24 hours of this treatment?
*
Yes
No
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Aftercare Advice
No extreme heat treatments (e.g. very hot baths or showers, saunas, steam rooms), swimming, sunbathing (including sun beds or any other exposure to UV light) for 24 hours.
Do not apply any perfumed products to the area for 24 hours.
Wash your hands before scratching or touching the area.
Avoid the use of make-up on the waxed area for 24 hours, apart from mineral make-up or specialist post-treatment products.
No self-tanning products to the area for 24 hours.
Do not pluck or tweeze in-between appointments particularly in areas where your esthetician has advised re-growth.
Please inform us immediately if you experience any problems after your treatment, including prolonged swelling, an itchy rash, bruising, or any kind of skin grazing, cuts or tearing so that we can advise the correct treatment. In the unlikely event that your skin does not return to normal within 24 hours of your treatment, seek advice from your physician in case you have had an allergic reaction to the wax or in case an infection is developing.
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Consent
Please check each box to show your understanding and agreement.
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Signature
This agreement will remain in effect for this procedure and all future facial wax procedures. I will alert the esthetician if there are any future changes to my medical history. I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to the facial wax procedure.
Signature
*
A copy of this signed agreement will be emailed to you.
Submit
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