Waxing Disclaimer

Waxing Consent & Release Form
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
Allergies
Select any allergies or sensitivities you have
Other allergies
Preferred Waxing Areas
Select the areas you would like waxed
Other waxing areas
Pregnancy
Are you currently pregnant?
Trimester
Is this considered a high-risk pregnancy?
Doctor / OB-GYN Name

First NameLast Name
Doctor / OB-GYN Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Pregnancy-related concerns
Photo Consent
Do you give permission to take before and after photos?
Do you give permission to use photos for marketing or social media?
If photos are used, may your face be covered?
Minor Consent
Are you under 18?
Parent / Guardian Name

First NameLast Name
Parent / Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Guardian Signature
Parent / Guardian consent acknowledgment
Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?
Are you using any other skin thinning products and/or drugs?
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
Waxing Consent & Release

Please read the following carefully before continuing.

Waxing may cause side effects such as skin removal, redness, swelling, tenderness, and similar reactions. I confirm that I have read and understood the information above, and that I have disclosed all known allergies, medications, and products I am currently using.

I give permission for the waxing procedure discussed and understand the risks involved. I agree to follow all aftercare recommendations provided to me and acknowledge that I am responsible for sharing any concerns or relevant medical information before treatment.
Signature
Date

DayMonthYear
Date
Should be Empty:

Waxing Consent & Release Form

Allergies

Preferred Waxing Areas

Pregnancy

Photo Consent

Minor Consent