Waxing Consent Form

Waxing Consent Form
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Name

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Walked byOnline SearchFacebook/InstagramReferral
How did you hear about us?

Walked byOnline searchFacebook/ InstagramReferral
If referred, by who?
Your Skin History
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?

YesNo
Have you used Retin-A, Renova, or Accutane within the past 3 months?

YesNo
When?

MonthDayYear
Date
Are you using any other skin thinning products and/or drugs that thin the blood?

YesNo
Do you use tanning beds on a regular basis?

YesNo
Are you prone to any of the following?

BruisingIngrown hairsHyperpigmentationScarringLiftingNone
Your Medical History
List medications/supplements you are currently taking?
List medications/ supplements you are currently taking.
Have you been treated for cancer? If yes, when and what types of therapies were used?
Do you have any open skin lesions?

YesNo
Do you have any allergies to cosmetics, latex, or topical treatments?

YesNo
Please list your allergies
By signing below I confirm that I am at least 18 years of age, or that a parent/ legal guardian is signing on my behalf. I also confirm by signing below that I have read and fully understand and accept the provisions of this document and that I consent to receive the waxing procedure.
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 Sophia Buck 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, or tanning; 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.
Signature
Should be Empty:

Waxing Consent Form

Your Skin History

Your Medical History