Name
First Name
Last Name
Waxing Waiver Form
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What are your skin concerns?
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Retinol, or Accutane within the past year?
*
Yes
No
When?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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
Are you currently taking any medications? If so, please list.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Please list any illness/conditions which ou are currently being treated for by a medical professional.
Do you have any open skin lesions?
*
Yes
No
Do you have any allergies?
*
Yes
No
Do you have any piercings?
Yes
No
Do you consent to photos/videos to be taken of your treatment and/or treated areas to be used for documentation and/or advertising?
Yes
No
Please list your allergies
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 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; no sexy time for 24 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 minimize or eliminate negative reactions as much as possible.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Submit
Should be Empty: