Client Consent: Waxing

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Are you using cream facial products such as Retin-A, Renova, Differin, Atralin, Epiduo, Tazorac etc? ( Has to be stopped 7 days before treatment and 7 days after. Products can leave the skin thin and sensitive which can cause burning and tearing of the skin. ) APPLIES TO FACE WAXING

Are you using any oral acne medication such as Accutane, Amnesteem, Vlaravis, Sotret etc? ( You should be off for at LEAST six months prior to appointment. Makes skin extremely sensitive and thin which will cause tearing of the skin. )

Are you using any other skin thinning products and/or drugs? If so, what kind

Other

Have you gotten Botox/Injections or chemical peels? ( Have to wait at least two weeks after treatment to get waxed. Waxing can alternate injections and chemical peels can cause severe sensitivity and burning. ) APPLIES TO FACE WAXING

Do you use any acne/facial cleaners that contain Benzoyl Peroxide? ( Has to be stopped 7 days before wax and 7 days after. Causes drying and irritation. ) APPLIES TO FACE WAXING

Are you diabetic? ( Makes you prone to infections. Need doctors note. )

Have you had radiation therapy? If so, when? ( Need doctors note in order to get waxed. )

Other

Do you have any open skin lesions or active herpes outbreak? ( Cold sore or genital ) ( You may NOT be waxed with an active outbreak. You will be declined service if it is active. )

Do you have any allergies, including allergies to wax or latex?

Do you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins? If so, what? ( Rosacea & eczema cracked or open skin is open to infection as well as rosacea can irritate that already dilated capillaries and cause a flareup. Severe varicose leg veins are known to make waxing more prone skin, lifting or wax burn. )

Other

Do you bruise easily?

Do you understand that waxing can have certain side effects such as skin removal, bruising, redness, swelling, tenderness, pimples, etc?

Will you follow proper waxing aftercare that your wax specialist informs you of?

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, bruising, pimples etc.

I have read the above information and if I have any concerns, I will address these with my waxer. I give permission to my wax specialist to perform the waxing procedure I am agreeing too 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 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 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. 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 Alidiaesthetics LLC 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.

Date

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