Waxing Intake/Consent Form

Name

First NameLast Name

Date of Birth

Phone Number

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

Have you used Alpha Hydroxy Acids (AHA) or glycolic products in the past 72 hours?

Are you currently (or have you ever) used Retin-A, Renova, or Accutane?

Are you diabetic?

Are you using any other skin thinning products and/or medication that thin blood?

If yes, please list.

Do you have any allergies?

If yes. please list.

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

Do you consent to photos/videos to be taken of your treatment and/or treated areas to be used for documentation and/or advertising?

Please note that waxing may 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 with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment.

I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minizime or eilimate negative reactions as much as possible.

Signature

EstheticallyMell