Waxing consultation & consent form

Name

First NameLast Name

Date

Birth Date

MonthDayYear

Phone Number

Area CodePhone Number

Email

example@example.com

How did you hear about me?

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?

Are you using any steroids or blood thinner medication/ products and/or drugs?

Are you using Retin-a, Renova, Tretinoin or Accutane (an oral form of Retin-a)?

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

Do you use a tanning bed?

Are you diabetic?

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):

What skin products do you regularly use on your skin?

Have you ever been treated for cancer? If yes, when and what types of therapies were used?

Please list any other illness/condition you are currently being treated for by a medical professional

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, menstrual cycle may cause sensitivity etc.

I confirm I have read the above information and if I have any concerns, I will address these with M.C.glowingskin I give permission to my esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand that M.C.glowingskin will take every precaution to minimize or eliminate negative reactions as much as possible.

I understand that I should keep the treated area free of products for 24 hours post-treatment. I am willing to follow recommendations made by M.C.glowingskin for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the my therapist immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold M.C.glowingskin responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Reservation & Cancellation Policy for all current and future appointments: A credit card is required to book and may be charged in the case of a late cancellation or a No-Call-No-Show. We ask that you please reschedule or cancel at least 24 hours before the beginning of your appointment. If you cancel with less than 24 hours notice or No-Show, you will be charged $50 or 50% of the service cost, whichever is greater. There is a 10-minute grace period for scheduled appointments. Arrivals later than 10 minutes will be considered a no-call-no-show and subject to the $50 fee. Late arrivals will result in shortened treatment time. Please do not foget to confirm your appointment when you receive your reminder from M.C.glowingskin

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release the skin care professional from liability and assume full responsibility thereof. I understand and voluntarily accept the risks associated with all services. I agree that this waiver is in effect for all services, and will not expire unless specifically requested by either party. By signing this form, I agree to the above terms, authorizing the skin care professional to retain my personal information on my private client account, and release the skin care professional from any liability or claims. Please print your name in the box and sign your signature below. Thank you.

Signature