Waxing Consent Form

Customer Name

First NameLast Name

Customer Email

example@example.com

Customer Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Parental Consent for Minors

Parent name

Parent Signature

How did you hear about Luna Rose Beauty Studios?

Client Referral Name

Please answer the health and skin checker for the safety of the procedure:

Rows	Yes	No	Remarks
Have you done any waxing before?
Are you currently taking any medications? If so please add under “Remarks”
Are you using any other skin thinning products and/or drugs that thin the blood?
Are you Pregnant? (Female)
Do you have sensitive skin?
Do you have any allergies?
Do you use tanning beds and/or are exposed to the sun on a regular basis?
Are you prone to scarring and hyperpigmentation?
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
Have you used Retin-A, Renova, or Accutane within the past year?
Have you been treated for cancer? If yes, has your Physician cleared you for waxing?
Do you have any open skin lesions?

I am providing my consent to complete the procedure I am requesting for I am duly aware of the side effects of waxing to my skin during or after the procedure such as:
skin redness, swelling, skin irritation, bruises, or bumps.

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 24-48 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.

I hereby affirm that I have read and fully understand the above, am over eighteen years of age and am legally liable for my own decisions/actions.

By signing below, it means that I agreed to the terms indicated in this document.

Date Signed

Date

Customer Signature

Waxing Consent Form

Waiver Consent