Brow wax/ Brow Tint Consent Form
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
*
Are you using any other skin thinning products and/or drugs that thin the blood?
*
Yes
No
Do you use tanning beds and/or are exposed to the sun on a regular basis?
Yes
No
Have you ever reacted to 3% peroxide or hair peroxide.
Yes
No
Have you ever had lumps, welts, heat rash or small white pimples appear above your brow, after having a treatment performed or after using a new facial product?
Yes
No
Have you spray tanned in the past week?
Yes
No
Have you recently had any facial treatments, peels, microdermabration, or skin needling?
Yes
No
Do you have any open skin lesions on the face?
*
Yes
No
Do you have any allergies? If so, please list.
Are you currently taking any medications? If so, please list.
Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these concerns with Sammy Beauty
I give permission to Sammy Beauty to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment.
I understand that Sammy Beauty will take every precaution to minimize or eliminate negative reactions as much as possible.
I have read, understand, and agree to all of sammy beauty’s policies. I understand that my card will be held on file and will not be charged without notice. I understand I will be subject to paying fees: 30% for any late reschedules, 50% for not showing up at my appointment without any notice, for the service(s) booked.
Name
First Name
Last Name
Date:
Signature
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