Waxing Consent Form

WAXING CONSENT FORM

GRACE & GLAMOUR BEAUTY BAR
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date

MonthDayYear
Date
HAVE YOU TAKEN ACCUTANE WITH THE PAST YEAR?

YESNO
ARE YOU 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
DO YOU CURRENTLY HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONSTHAT COULD COMPROMISE YOUR SKIN AND/OR SERVICES BEING OFFERED:

AIDS/HIVECZEMA/PSORIASISCOLD SORES/FEVER BLISTERSHEPATITISHERPESVARICOSE VEINSCANCER
**PLEASE READ THE FOLLOWING WARNINGS**

IF YOU ARE USING ANY OF THE FOLLOWING MEDICATIONS, YOU CAN NOT BE WAXED TODAY:
- ACCUTANE - RENOVA
- TRETINOIN
- ADAPALENE - ALUSTRA
- AVAGE
- ISOTRETINOIN - RETIN-A
- AVITA - TAZAROTENE - 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 CONSENT (OVER 18 YRS OF AGE):
CLIENT CONSENT (OVER 18 YRS OF AGE):
PARENT/GUARDIAN CONSENT (UNDER 18 YRS OF AGE):
I, Your Name AUTHORIZE Desired Treatment WAXING TREATMENT ON Minor's Name , A MINOR.
Should be Empty:

WAXING CONSENT FORM

CONSENT AND SIGNATURE:

CLIENT CONSENT (OVER 18 YRS OF AGE):

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