Body Contouring Client Consent & Intake Form

Date

Name

First NameLast Name

Age

Date of Birth

Date

Gender

MaleFemale

Email

example@example.com

Phone Number

Please enter a valid phone number.

Emergency Contact Person

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.

How did you hear about us?

HAVE YOU EVER HAD A WAXING SERVICE?

YESNO

IF YES, PLEASE DESCRIBE

DO YOU HAVE VERICOSE VEINS ON YOUR LEGS?

YesNo

DO YOU USE GLYCOLIC ACID, SALYCIC ACID, LACTIC ACID OR ANY OTHER ACID BASED PRODUCTS ON YOUR FACE OR BODY?

YesNo

HAVE YOU RECENTLY HAD MICRODERMABRASION, LASER RESURFACING, OR INJECTABLE FILLERS?

YesNo

HAVE YOU OR WILL YOU BE IN THE SUN OR TANNING BED WITHIN 24 HOURS OF THIS TREATMENT?

YesNo

ARE YOU CURRENTLY TAKING ANY ACNE MEDICATIONS? If yes, please list them below.

TREATMENT AREAS:

I understand That by signing below that topic creams, medical conditions, and certain medications can affect the results of waxing. I understat that I can not be waxed if i have certain contraindications and I hereby release Retreat Body and Wellness (Retreat BX) harmless and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, cost, expenses, and compensation for damages or loss to myself and or property that may be caused by any act or misinformation both intentional and/or accidently on this form as well as failure to follow post-care instructions after my service

I understand that any procedure involves risk. Risks may include redness, swelling irritation, skin reaction.

I have been honest and forthright about my medical history, and am healthy to receive this service.

Acknowledgment: I understand each person has a different response to this treatment. The risks, benefits, and possible results have been explained to me. I have been provided with the opportunity to ask questions and received satisfactory responses.

I voluntarily provide my consent to partake in the waxing treatment. Should any pain or discomfort occur I will immediately notify Retreat Bx staff.

I will not hold Retreat Bx, staff/employees, or subcontractors liable for any irritation, discomfort, or effects of having this treatment.

Your Signature

Date Signed

Date

I understand that this activity might lead to personal injury therefore I release Retreat BX & all employees or contactors to any liabilities like personal injury and damage. I also authorize Retreat Bx to make medical decisions for me if needed and if unable to contact an emergency contact person.

Your Signature

Date Signed

Date

WAXING INTAKE FORM / LIABILITY WAIVER

Patient Information

Medical Condition

Acknowledgment

Liability Waiver