Waxing Consent Form

Waxing Consent Form
Name*

First NameLast Name
Appointment Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Referred by:*

GoogleDriving byFriendClient
Date of birth*
No alcohols, astringents or powders can be applied before removal.

After the removal is complete, finipil antiseptic will be applied to instantly cool and protect the now empty follicle.
Have you taken Accutane in the past year?*

YesNo
Are you currently using Retin-A, Differin or Renova?*

YesNo
Are you taking any medications that make you photosensitive?*

YesNo
Do you frequent tanning beds?*

YesNo
Are you currently sunburn?*

YesNo
Are you diabetic?*

YesNo
If you have any medical conditions that could effect your skin during the waxing services, make them known by selecting the appropriate boxes below.*

AIDS/HIVEczema /PsoriasisHerpes (Cold Sores /Fever Blisters)HepatitisCancerVaricose VeinsNone of the above
Read the warnings and the consent paragraph before signing the document. If you are under 18 years of age, a parent or guardian must complete the bottom section of the consent form.
If you are using any of the following medications, you cannot be waxed today:

Accutane ~ Adapalene ~ Isotretinoin ~ Retin A ~ Renova ~ Alustria ~ Avita ~ Tazarotene ~ Tretinoin ~ Avage ~ Differin

You may experience skin sensivity / thinning, which can result in skin lifting, from the following:

*Sunburned skin

*Retinol

*Certain medical conditions

*Pregnancy

*Antibiotics

*Menstruation

*Other medications not listed
In order for your technician to perform an efficient hair removal, you must have at least 7-10 days hair growth for your 1st appointment and your 2nd appointment should be atleast 3-4 weeks later.
CONSENT AND SIGNATURE:

I understand that if I being use, or are currently using, any of the products listed in the above warning anddo not inform the technician prior to current or future appointments, I accept full responsibility for any adverse reactions.

I understand that waxing may cause some redness, bumps, soreness and/or itching.
I am over 18 years of age, and by typing my name below, I confirm to the best of my knowledge that the answers I have given are correct and I have not withheld any information. *
PARENT/GUARDIAN CONSENT (UNDER 18 YEARS OF AGE):
I, First Name Last Name authorize Dolce Organic Salon, Med Spa & Salt Room to perform a waxing treatment on First Name Last Name (minor).
By typing my name below, I consent to treatment for the minor listed.
Should be Empty: