Waxing Service Consultation Form

Please answer the health and skin questionnaire for the safety of the service:

Rows	Yes	No	Remarks
Have you done any waxing before?
Are you currently taking any medications?
Have you had any skin thinning treatments before?
Are you Pregnant?
Do you have sensitive skin?
Do you have any allergies? (if so, please list)
Do you bruise easily?
Are you prone to scarring and hyperpigmentation?
Are you using any skin thinning products or products that thin the blood?
Do you use tanning beds or are you exposed to sun regularly?
Do you have any open skin lesions?

Accutane Retin-A or retinoidsRenovaDifferinAHA (alpha hydroxy acid)BHA (salicylic acid)Glycolic Acid
Emergency Contact

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Emergency Phone
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Consent For Service

*Please note that waxing can have side effects such as redness, swelling, tenderness, and in some cases skin removal*
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 (and intimacy, for Bikini/Brazilian wax only) 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.
Customer Signature

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Consent For Service