ClientInfo-Consent-Waxing

Client Information and Consent-Waxing

Name*

First and Last Name

Address*

City*

State*

Zip*

Home Phone*

Work Phone

Email address*

example@example.com

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? Yes/No

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? Yes/No

Are you using any other skin thinning products and/or drugs? Yes/No

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon? Yes/No

Do you use a tanning bed? Yes/No

Are you diabetic? Yes/No

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 theraples were used?

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

(Female clients) When is your next menstrual cycle due to begin? alow fivo days for monstrual cycle. Bocause of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle 6 due and two days after tis completed)

(Female clients) When is your next menstrual cycle due to begin?

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. have read the above information and if have any concerns, will address these with my skin thorapist. give permission to my therapist to perform the waxing procedure we have discussed and will hold hor and hor staff harmless from any libility that may result from this treatment. I have givon an accurate account of the questions asked above including all known allergies or prescription drugs or products am currently ingesting or using topically. understand my esthetician will take overy procaution to minimizo or eliminate negativo reactions as much as possible. I have read and understand the post-treatment home care instructions. am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible nogative reactions. In the event that may have additional questions or concerns regarding my troatment or suggested home product/ post-treatment care, will consult the esthetician immediately. 1 agree that this constitutes full disclosure, and that it suporsedos any previous verbal or written disclosures. cortify that have read, and fully understand the above paragraphs and that have had sufficient opportunity for discussion to have any questions answered. understand the procedure and accopt the risks. do not hold the esthetician, whose signature appears below, 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.

Client Name (printed)*

Client Name (signature)*

Date*

Date

Esthetician

Date