Appointment Request Form

Waxing & Service Consent Form

Thank you for taking the time to complete the consent form .
Client Name

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please fill out the questionnaire for safety and best results

	YES	NO	Notes / Comments
First Time Waxing ?
Are you currently using acne medications (prescribed or over the counter) Including: Retin -A , Differin, or other retinoids ?
Have you had any skin thinning treatments recently? Or taken Accutane within the past 12 months ?
Are you pregnant?
Do you have rosacea , eczema , psoriasis, cracked or open skin , severe varicose veins, or any skin sensitivities ?
Do you have any skin allergies ? If so , What are you allergic to ?
I am over 18 years of age or I have parental consent signed below
I do not have any open skin lesions or active herpes outbreak ( cold sore or genital )

Are you currently using any cosmetic products that may contain the following substances? Kindly check if yes and if no,leave blank.
Accutane Retin -A or retinoidsRenovaDifferinAHABHAGlycolic AcidNone of theseOther
Waiver Consent

I am providing my consent to complete the procedure I am requesting for I am dully aware of the side effects of waxing to my skin during or after the procedure such as : skin redness, swelling, skin irritation, bruising or bumps. I acknowledge and completed health and skin check list , efficiency , and accuracy. I was instructed and enlightened that some cosmetic additives or chemical substances itemized were hazardous when coupled with waxing and may most likely cause disappointing results and side effects to my skin area. I hereby affirm that I have read and fully understand the above, am over eighteen years of age and am legally liable for my own decisions/actions. By signing below, it means that I agreed to the terms indicated in this document.
Client Signature

Powered by Jotform SignClear
Date Signed

MonthDayYear
Date
Should be Empty:

Waxing & Service Consent Form