VIDA ROSE ESTHETICS
WAX INTAKE/CONSENT FORM
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Age?
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?
*
Yes
No
When?
*
-
Month
-
Day
Year
Date
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 ou are currently being treated for by a medical professional.
*
Do you have any open skin lesions?
*
Yes
No
Do you have any allergies?
*
Yes
No
Please list your allergies
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 with my Esthetician. I give permission to my Esthetician 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; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Submit
Should be Empty: