Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Age
*
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
*
Have you received a chemical peel or microdermabrasion in the last 7 days?
*
Yes
No
Are you using any other skin thinning products and/or blood thinning medications?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
Yes
No
Are you currently taking any medications? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any illness/conditions which you are currently being treated for by a medical professional.
Do you have any open skin lesions on the face?
*
Yes
No
Do you have any allergies? If so, please list.
Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and have given an accurate account of the questions.
I give Rianna's Aesthetic Studio permission to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment.
I agree to adhere to all safety post care including: no peels, tanning, or swimming pools/spas/hot tubs for 72 hours after waxing.
I understand that Rianna's Aesthetic Studio will take every precaution to minimize or eliminate negative reactions within the scope of their control.
Signature of Client
Date:
Submit
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