Waxing Consent Form

Waxing Consent Form
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
Birth Date*

MonthDayYear
Date

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):
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?
Please list any other illness/condition you are currently being treated for by a medical professional
*Female clients* When is your next menstrual cycle due to begin? (Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)

MonthDayYear
Date

Cancellation Policies
I consent
I consent
I consent
Photo Release

(optional)
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area.

Photographic, audio or video recordings may be used for the following purposes:

• educational presentations or courses

• informational presentations

• on-line educational courses

• educational videos

• promotional materials

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.
YESNO
DISCLOSURE:

Please note that waxing does have certain side effects such as possible skin removal, redness, swelling, tenderness, etc.

I have read the above information 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 and her staff harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions. I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
I agree with all terms & disclosure.
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Date
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Waxing Consent Form

Cancellation Policies

Photo Release