Waxing Consent Form

Waxing Intake and Consent Form

Please complete this form before you arrive at the Studio. Fields marked as * are mandatory. Sign and date the form, then click submit when you are finished.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*

Area CodePhone Number
Phone Number*
Birthdate*

MonthDayYear
Are you currently taking Retin A, Renova, Differin or other types of skin thinning ACNE MEDICATIONS, orally or topically?*

YesNo
Have you used Accutane within the past year?*

YesNo
Are you currently using any BLEACHING AGENTS for your facial or body hair or bleaching agents for pigmentation (Hydroquinone, Trilumena), Alpha Hydroxy Acids (Glycolic, Lactic), Salicylic Acids or other exfoliants?*

YesNo
Are you using any other skin thinning products and/or drugs that thin the blood?*

YesNo
New or continued use of certain medications or agents increases the possibility of a reaction. Certain products can make the skin more sensitive. Thin, sensitive skin is more vulnerable to lifting and sensitivity during waxing. Individuals do react differently to medications and sometimes waxing can be done if proper test patching is completed. We encourage test patching an area, if you are concerned, prior to waxing. Please inform your technician if you have begun taking any new medications since your last visit.
Do you use tanning beds and/or are exposed to the sun on a regular basis?*

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

YesNo
Are you prone to ingrown hairs?*

YesNo
Are you prone to bumps?*

YesNo
Do you have any open sores or skin lesions?*

YesNo
Any other illness/condition/allergies for which you are receiving medical treatment and which may impact your service(s)?
PRECAUTIONS AND CONSIDERATIONS:
- Sun exposure (direct sun or tanning bed), irritated or areas with open skin cannot be waxed.
- We recommend avoiding any sun exposure up to 48 hours following your waxing service.
- We recommend no standing water for 48 hours following your waxing service, this includes: hot tubs, baths or swimming pools.
- We recommend avoiding using deodorants, fragranced lotions, tanning
  accelerators or abrasives 24 hours after your waxing service.
- Microdermabrasion or “peels” should not be done 3 days pre- or post- service.
By signing below I hereby voluntarily request, permit, and authorize the administration of waxing services by a licensed cosmetologist. I confirm to the best of my knowledge that the information I have provided is accurate and complete, and I have received general information about the service I am seeking. I have not withheld information that may be relevant to the services or the results thereof. I am aware that there are often inherent risks associated with waxing and trimming procedures, and the services I am about to receive could have unfavorable and uncomfortable results, including but not limited to: allergic reaction, irritation, burning, redness, scarring, soreness, etc. By signing below, I freely assume these risks and I agree that I will not hold Gary Brito Studio/Gb Manscaping or its owner or any of its employees responsible should there be any unfavorable outcome or result. I will inform Gary Brito Studio/Gb Manscaping of any complications or concerns I may have as soon as they occur, and any changes to the information in this form. I have read, understand, and agree to the above provisions.
Signature*

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Date

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Date
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Waxing Intake and Consent Form