Waxing and Tinting Consent Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Emergency Contact

First NameLast Name

Emergency Contact Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Date of Birth

Date

How did you hear about us?

I have agreed to have the following procedure done today by my licensed professional, Body or Facial Waxing and/or Eyebrow or Eyelash Tinting. By signing this form I acknowledge that I have read and understand the process and that all of my answers on this form are truthful to my knowledge. My technician has explained to me in depth the procedure and has answered any and all questions I have regarding what is to be performed.

SOCIAL MEDIA CONSENT

No

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72hours?

Are you using Retin-a, Tretinoin, Renova or Accutane (an oral form of Retin-a)?

Are you exposed to the sun on a daily basis or are you considering spending more time inthe sun soon?

Do you use a tanning bed?

Are you diabetic?

Are you currently taking medications? If so, please list all (including over the counterdrugs/herbal supplements)

If yes to the question above, please specify:

Have you had a sunburn in the past 14 days?

Have you ever been treated for cancer? If yes, when and what types of therapies were used?

If yes to the question above, please specify:

Have you ever had your brows or lashes tinted?

If you had an adverse reaction to a previous tinting, please explain:

If no to the question above, would you like to have a patch test performed? If so, you will need to wait at least 24 hours to see if a reaction occurs. (Note that a patch test does not guarantee that an adverse reaction will never happen, you may develop an allergy at any time)

Please list any other illness/condition you are currently being treated for by a medical professional

Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below.
Please check below to agree:

I request and consent to these procedures being carried out today without undergoing a sensitivity patch test. The sensitivity test, which if conducted may indicate my sensitivity / allergy to the products. I understand the contents of this form and take full responsibility for my actions, thus absolving all other parties of their responsibilities, if any, associated with the supply of the products and services(s).

I, Name:* , certify that the information provided in this form is accurate
and complete to the best of my knowledge. I have read, understood, and answered all
questions truthfully. I have discussed any concerns or questions with the technician,
and I have read and understood the aftercare instructions provided to me. I agree to
inform the technician of any changes to my medical history, eye or skin conditions, or
concerns. I will not hold the salon or technician responsible for any issues not disclosed at
the time of my service or any adverse effects from the Waxing or Eyebrow/Eyelash Tinting procedure.

Name

First NameLast Name

Date

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist 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 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, Deanna Ayala of Sublime Beauty, 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 have read the above information. If I have any concerns, I will address these with my
skin care therapist. I give permission to my therapist to perform the tinting procedure we
have discussed, and will hold him/her and Sublime Beauty harmless from any liability that
may result from this treatment. I have accurately answered the questions above, including
all known allergies, 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. In the event I may have additional questions or
concerns regarding my treatment, 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, Deanna Ayala of Sublime Beauty, 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

Name

First NameLast Name

Date