Waxing Consent Form
Name
*
First Name
Last Name
Today’s Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?
*
Yes
No
Are you using any other skin thinning products and/or drugs?
*
Yes
No
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
*
Yes
No
Do you use a tanning bed?
*
Yes
No
Are you diabetic?
*
Yes
No
Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):
*
Please list any known allergies:
*
What skin products do you regularly use on your skin?
*
Have you ever been treated for cancer? If yes, when and what types of therapies were used?
*
Please list any other illness/condition you are currently being treated for by a medical professional
*
I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.
*
I have cited all conditions and circumstances regarding my health history, medications being taken, allergies, and any past reactions to products or medications.
*
PLEASE NOTE: Waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information 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 and Grace Skin Studio harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician or Grace Skin Studio responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. By signing below, I verify that I have read and understand the above statements and agree to them.
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Submit
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