Hair Removal & Skin Treatment Waiver Form

Hair Removal & Skin Treatment Waiver Form

Required to be filled and submitted prior to appointment.
Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearIf you are under 18 and booking for a Brazilian, you will need a parental consent.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Have you received any of these hair removal services in the last 30 days?
Your Health

A complete health history helps us ensure it is safe to provide you with services. All information is confidential.
Do you have a history of any of these health conditions?
Please explain or list other health conditions:
Are you taking any prescription medications (topical or internal)?
If Yes, please list:
Are you diabetic?
What skin products do you regularly use on your skin?
Have you ever been treated for Cancer? If yes, when and what types of therapies were used?
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differin, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives?
Please specify which product or type, if you answered 'Yes, currently using' to above.
If other, please list
Any known allergies?
Please Specify:
Have you used or been prescribed any medications )topical or oral) for acne / acne control?
If Yes, please specify what and date last used
Are you pregnant or trying to become pregnant?
Female Clients
Have you received this type of service before?
Consent: I understand that if I am waxing one week before or one week after my menstrual cycle, I may experience more sensitivity. Waxing may cause: Bruises, scabs, scarring, redness, hyper-pigmentation or pimples. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. (Most commonly occurs in Brazilian & Bikini wax services). I understand all the above-mentioned reactions. I also understand if I change my skincare routine or medications, I must inform the professional PRIOR to starting any services in the future. I have been fully informed about the expected results and effects of waxing and agree to follow all aftercare advice provided by my therapist. I hereby give my consent to proceed with the treatment.
Late Policy: If you are more than 10 minutes late we cannot guarantee your appointment time. Depending on our bookings for the day, we may need to reschedule your service. We understand that life happens and will try our best to accommodate you.
Service Provider: If your service provider is out on the day of your service, we may move your appointment without notice to someone that is available. However, we will do our best to notify you.
Cancellation Policy: Please provide 48-hour notice if you need to cancel or change your appointment. Your first missed appointment will be excused, but if it occurs frequently, we will need to keep a credit card on file. There will be a 50% service charge for missed appointments. If you are sick, please let us know and until further notice, cancellation fee will be waived.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
Signature
Should be Empty:

Hair Removal & Skin Treatment Waiver Form

Your Health

Female Clients