Wax Consent Form

Wax Consent Form

Please read and complete the following consent form to ensure a safe and comfortable waxing experience.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Have you taken Accutane within the past year?
Are you using Retin-A, Differin, or Renova?
Are you currently taking any medication?
Are you currently using any self-tanners?
Do you frequent tanning beds?
Are you currently sunburned?
Are you diabetic?
Are you currently pregnant?
Pregnancy and Waxing:

Please be aware that hormonal changes during pregnancy can increase skin sensitivity. While waxing is generally safe during pregnancy, you may experience more discomfort than usual. If you are pregnant or think you may be pregnant,please inform your esthetician so we can discuss the best options for your comfort and safety.
Do you currently have any of the following skin conditions or any other skin sensitivities that we should be aware of? Please check all that apply.

Other
If “Other” was selected. Please explain. Please note that all information will be kept confidential.
When was your last waxing session?
Have you ever experienced any adverse reactions to waxing? If so, please explain. If not applicable, simply write, “No”.
To ensure your comfort and safety during your waxing appointment, please list any medical treatments or procedures you’ve received on the areas to be waxed within the past 6 months. This includes, but isn’t limited to: Surgeries, Laser Therapies, and Chemical Peels. If you haven’t had any treatments in this timeframe, simply write, “None”.
For your safety and to ensure the best results, are you currently taking any medications, including prescriptions, over-the-counter drugs, or topical creams? If so, please list them so I can make sure there are no contraindications with waxing. If none, simply write “None”.
Some waxing products or aftercare lotions may contain ingredients that can cause allergic reactions in certain individuals. To ensure your safety and comfort, please list any known allergies below. If you do not have any allergies, please write “None”.
PLEASE NOTE - If you are using any of the following medications, you cannot be waxed today:

Accutane, Adapalene, Isotretinoin, Retin-A, Renova, Alustra, Avita, Tazarotene, Tretinoin, Avage, or Differin.
Do you currently have or have you had any of the following medical conditions that could compromise your skin and/or services being offered? Please note that all information submitted will be held confidential.
YOU MAY EXPERIENCE SKIN SENSITIVITY/THINNING, WHICH CAN RESULT IN SKIN LIFTING, FROM THE FOLLOWING:

Sunburned skin, retinol, certain medical conditions, pregnancy, antibiotics, other medications not listed, or menstruation.
CONSENT AND SIGNATURE

I understand the risk and dangers of waxing and agree to hold harmless Jennifer Hinostroza, and Roselux Spa of all liability in relation to the service being provided. I agree if I begin to use, or are currently using, any of the products listed in the above warning, and do not inform Jennifer Hinostroza and Roselux Spa prior to current or future treatment, I accept full responsibility for any adverse reactions. It is understood that waxing may cause some redness, bumps, soreness, and/or itching.
Signature
Parent/Guardian Consent (Under 18 years of age)
I, (Parent/Guardian), authorizeJennifer Hinostroza/Roselux Spa* to provide waxing services to First Name Last Name .

Signature of Parent/Guardian: Signature Date:
Should be Empty:

Wax Consent Form

PLEASE NOTE - If you are using any of the following medications, you cannot be waxed today:

YOU MAY EXPERIENCE SKIN SENSITIVITY/THINNING, WHICH CAN RESULT IN SKIN LIFTING, FROM THE FOLLOWING:

CONSENT AND SIGNATURE

Parent/Guardian Consent (Under 18 years of age)