Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you 18 years of age or older? **If no, a parent/guardian must be present during your first appointment. Brazilian Waxing will not be performed on clients under the age of 18**

YesNo

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the 72 hours prior to your appointment? **You must be free of these products for 72 hours prior to hair removal**

YesNo

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? **If yes, hair removal services will not be performed**

YesNo

Are you using any other skin thinning products and/or drugs?

YesNo

Please list any/all allergies:

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

YesNo

Do you use a tanning bed?

YesNo

Are you diabetic?

YesNo

Please list any medications you currently taking medications:

Have you ever been treated for cancer? If yes, when and what types of therapies were used:

Are you pregnant or expecting a menstrual cycle?

PregnantExpecting cycleNo

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

Please note: Waxing can have side effects such as redness, swelling, tenderness, skin lifting, 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 her staff 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, 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 have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for
a home care regimen that can minimize or eliminate possible negative reactions.

*Water retention can cause temporary puffiness or reddening, especially on the facial/sinus areas. Your technician will take a precautionary thumb print test to see if this may occur, and if he/she feel it may, they will apply a cold wet compress over the finipil antiseptic after the hair removal for 60 seconds.

In order for your technician to perform an efficient hair removal you must have at least 7 to 10 days of hair growth from your 1st appointment and 3 to 4 weeks of hair growth for your 2nd appointment.

I confirm to the best of my knowledge that the answers I have given are correct and I have not withheld any information:

Signature

Waxing Consent Form