WAXING WITH RONE LLC

CUSTOMER NAME

First NameLast Name

CUSTOMER EMAIL

example@example.com

CUSTOMER ADRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CUSTOMER PHONE NUMBER

Please enter a valid phone number.Format: (000) 000-0000.

Age:

GENDER

FOR SAFETY PURPOSES PLEASE ANSWER THE FOLLOWING QUESTIONS BELOW.

Rows	Yes	No	Other
Is this your first time getting waxed?
Are currently taking any medications?
Are you currently Pregnant?
When is your next Menstrual (cycle)?
Do you have sensitive skin?
Do you have any allergies?
Are you prone to Ingrowns/hyperpigmentation?

ARE YOU USING OR TAKING THE FOLLOWING:

Rows	Yes	No
Accurate or Tetracycline
Retinoids such as Retin-A, Renova or Diferin
AHA/Alpha-Hydroxy Acid
BHA/Beta-Hydroxy Acid
Glycolic Acid

Other Medications:

I give permission to the Esthetician to perform the waxing procedure and will hold (WAXINGWITHRONE) harmless from any liabilty that may result from this treatment.

Waxing is a method of temporary hair removal which removes the hair from the root. I understand that waxing may have some side effets including redness,scabbing,bruising, swelling or Tenderness.

I have given an accurate account of the questions asked above including known allergies or perscription drugs or products I am ingesting or using topically.

I agree to adhere to all post treatments aftercare including:No gym,sex,tanning,saunas for 24/48 hrs after waxing;and all home care protocols recommended by the Esthetician that can maximize or eliminate possible negative reactions. I will contact my Esthetician of any complications or concerns I may have as soon they occur.

I have completed this form to the best of my ability and knowledge & agree to inform the Esthetician of any changes in the information stated. I will inform the Esthetician of any discomfort that I may experience at any time during this treatment to allow the Esthetician to adjust accordingly. I agree to wave all liabilities toward (WAXING WITH RONE) for any injuries or damage that may occur during the treatment due to any misrepresentative of my health history.

Signature

Date Signed

Date