Waxing Consent Form

Appointment Date

Date

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Date of birth

How did you hear about us?

If friend /client referral, please list name so they can get reward points

No alcohols, astringents or powders can be applied before removal.

Have you taken Accutane in the past year?

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

Are you taking any medications that make you photosensitive?

Do you frequent tanning beds?

Are you currently sunburn?

Are you diabetic?

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

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 at least 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.