Brow Wax / Tint & Lash Lift / Tint Consent
Name
*
First Name
Last Name
Age?
*
Sex
Female
Male
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
*
Yes
No
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
*
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 you are currently being treated for by a medical professional.
Do you have any open skin lesions on the face?
*
Yes
No
Do you have any allergies? If so, please list.
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 concerns with owner and operator of Beauty X Glam Esthetics LLC .
I give permission to Beauty X Glam Esthetics LLC. 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.
I understand that Beauty X Glam Esthetics LLC . will take every precaution to minimize or eliminate negative reactions as much as possible.
I understand Beauty X Glam’s policies & rules, and consent to services.
Yes
Client Signature
*
Date:
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