Waxing Consent Form

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.

Email

example@example.com

Birthday

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

Have you used Retin-A, Renova, or Accutane within the past year? If so, when?

Are you using any other skin thinning and/or drugs that thin the blood? If yes, please explain.

Do you use tanning beds and/or are exposed to the sun on a regular basis?

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

Are you currently taking any medication? If yes, Please list.

Please list any illness and/or conditions which you are currently being treated for by a medical professional.

Do you have any open skin lesions?

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the information above and if I have any concerns , I will adress these with my esthetician.I give my permission to my esthetician to permform the waxing procedure we have dicussed and will hold her/him 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 my esthetician will take every precaution to minimize or eliminate negative reactions much as possible.

I am willing to follow reccomendations made by my esthetician 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 my esthetician immediately.

I have read and agree that this constitutes full disclousre, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the paragraphs above and that I have had sufficient opportinuty for discussion to have any questions answered. I understand the procedure and accept the risks.I do not hold the esthetician, whose signature appears below, responisble for any conditions that were present, but not disclosed at the time of the skin care procedure ,which maybe affected by the treatment performed today.

Name Printed

Signature

Date