Waxing Consent Form

Name*

Address

Street Address Line 2

City

State

Zip

Cell Phone*

Format: (000) 000-0000.

Email

example@example.com

How often do you have waxing done?*

Have you ever had a reaction to a waxing service?*

YesNo

If yes, please describe:

Do you have any tendencies to:*

Are you allergic to anything?*

YesNo

If yes, please describe:

Have you received Botox treatments in the last 72 hours?*

YesNo

Have you been or will you be in the sun and/or tanning bed within 24 hours of this treatment?*

YesNo

(Select all that applies to you) Are you using or taking:

Any other medications:

Are you currently pregnant?

YesNo

Do you have Diabetes, Phlebitis, or any skin irritations?

YesNo

Is there anything you would like for us to know?

I have been advised the service(s) provided to me by this spa could have unfavorable results including, but not limited to: allergic reaction, irritation, burning, redness, soreness, ect. I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services. I understand that Me Time Sanctuary does not recommend skin care services for customers using Retin-A, Acutane and products contacting alpha hydroxyl, or any other skin thinning treatments. I hereby confirm that I am not using any medications that may cause or contribute to such injury/reaction, and I will advise my esthetician should I use any such medications in the future. I understand there are often inherent risks associated with skin care services, and I agree that as a condition of providing these services on an on going basis, I will not hold Me Time Sanctuary and Esthetician liable.

Signature*

Date