Waxing Consent Form

Waxing Consent Form
Name

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
Have you used Retin-A, Renova, Accutane or other retinoid products within the past year?
When?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you using any other skin thinning products and/or drugs that thin the blood?
Have you recently received any exfoliating treatments or chemical peels?
Do you use tanning beds and/or are exposed to the sun on a regular basis?
Are you currently taking any medications, including antibiotics? 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 for which you are currently being treated by a medical professional.
Are you currently pregnant?
Are you menstruating or about to begin menstruating?
Are you taking birth control, or hormone replacements?
Do you have any cracked or open skin lesions, rosacea, eczema, psoriasis, severe varicose veins, or any other skin sensitivities?
Do you have any allergies?
Please list your allergies
Side Effects

Waxing may cause side effects. The side effects listed here are merely examples and are not intended to be an exhaustive list. Every person is different, and there is no guarantee that you will not experience more severe side effects. The most common side effects include quickly dissipating, mild discomfort when the wax removes hair from its follicle. Waxing may cause inflammation, welts, hives, skin lifting, and reddening or small breakouts. This is usually not severe and typically will subside within a few days at most. Please contact us immediately if you experience more severe or long-lasting side effects.
Waiver

I understand and acknowledge that there are risks involved with all waxing procedure(s), including, but not limited to, those side effects listed above. I understand that any false or misleading information I have given may result in undesired effects and complications and hereby waive GENTLE WAX’s liability if such results or complications should occur. I further understand that my failure to follow post-procedure instructions may also lead to undesired results, complications or effects and hereby waive GENTLE WAX’s liability if such results or complications occur. In consideration of GENTLE WAX performing this procedure(s), I agree that I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur while I am undergoing this procedure(s) or side effects I may experience after the procedure(s) is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against GENTLE WAX, its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of the procedure(s).

By signing below, I certify that I have read and fully understand all of the above information, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to, and authorize GENTLE WAX to perform, the procedure(s) described above on me.
To the client: You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask GENTLE WAX of SARASOTA any questions you may have and to consult with a healthcare provider if you have additional concerns.
Before & After photos are a simple way to demonstrate the effects of our specialized waxing method. Photos are not always taken, but when they are, will only include the area being waxed will be shown in a cropped fashion, maintaining my privacy and identity. ALL INTIMATE WAXING BEFORE & AFTER PHOTOS USE LAMINATED CUTOUTS TO VISUALLY PROTECT THE PRIVATE AREAS OF THE BODY.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: