Hair Removal Consent Form
In order to better assess and best course of treatments, please complete thoroughly, if something does not pertain to you, please put 'n/a.' Failure to fully disclose information, can result in unfavorable results. The information you provide is confidential and will not be shared with any other party.
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Email will be used for email confirmations and newsletters only to stay up to date with special offers and news about Luxe Skin Care. (we will never spam you or sell your information). Please select option below.
Appointment Reminders Only
Appointment Reminders & Newsletters
How did you hear about me?
If referral, who may we thank?
When was the last time you shaved/waxed/sugared? (2 weeks of hair growth is recommended)
Do you or have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives? (You must be off Accutane for one year to wax or sugar. You must be off all other actives 7 days before)
Yes, currently using
Yes, but not within the last 30 days
Yes, but not within the last 6 months
Please specify which product or type, if you answered 'Yes, currently using' to above.
If checked, please note date last used.
Have you ever received chemical peels, laser services, or microdermabrasion treatments?
Yes, within the last month
Yes, within the last 2-3 months
Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? (you must wait 2 weeks prior to any facial injections for waxing or sugaring of the face.)
How frequently are you exposed to the sun or use a tanning bed?
Have you been under the care of a physician, dermatologist or other medical professional within the past year?
If yes, please explain
Any recent surgery, including plastic surgery?
If yes, please explain
Have you experienced any of these health conditions in the past or present?
Cancer / Systemic Disease
High Blood Pressure
Epilepsy / Seizure Disorder
Frequent Cold Sores
Headaches / Migraines
If you checked yes to any of these please provide further information. If not mark N/A
Do you have or are you prone to?
Wear contact lenses
Have a pacemaker
Have metal implants
Have body piercings
No, not applicable
Do you take any of the following dietary / health supplements/medications?
Omega 3 / Fish Oil
B Complex / B12
If other or any medications, please list all:
Any known allergies?
If any checked, please specify
Have you used or been prescribed any medications (topical or oral) for acne / acne control?
If yes, please specify what and date last used
Are you taking birth control?
If yes, what brand?
Are you pregnant or trying to become pregnant?
Recently had baby & am breastfeeding
Any menopause issues?
If yes, please specify
Are you undergoing any hormone replacement therapy?
If yes, please specify
Post Care Instructions/Consent to treatment
After your treatment, the use of sunscreen with SPF 30 or higher is mandatory and must be worn every day. Sun bathing(tanning bed or laying in the sun) should never be used. Sun exposure on waxed or sugared skin makes you more prone to sunburn. You are investing in your skin and to help achieve desired results, it is to your benefit to always be diligent with your sunscreen protection.
I understand that no treatment will be preformed with any open lesions, active or healing cold sores(scab must be off and healed) or anything potentially contagious for your protection and ours.
I understand that even if I have never had or am prone to cold sores or any herpes simplex outbreaks, that waxing or sugaring may trigger an outbreak.
DO NOT participate in any activities for 24-48 hours such as exercise, vigorous physical activities that would cause your body to perspire or heat as this can cause bumps and irritation to area waxed or sugared.
Do NOT go swimming, use hot tub or sauna 24-48 hours hair removal treatment.
DO NOT use scrubs, chemical exfoliation, handheld exfoliation devices or any other means for 3 days.
It is recommended to avoid make up application of any sort day of your facial hair removal treatment.
As every precaution is taken to ensure skin is calm and hydrated, you may experience dryness, flaking, redness or tenderness. Always contact me with any concerns.
To help prevent ingrowns, bumps and to maintain your treatments, I encourage regular exfoliation with Kami Mitt and hydration with Silky Streak on the body as this removes dead skin build up around and in the follicle and hydrates the skin without building up in the follicle, again aiding in easier and more thorough removal. Both can be purchased via our website or at the clinic. You understand failure to maintain your skin at home can hinder your hair removal results.
Your appointments are reserved especially for you. Please understand that when you forget or cancel your appointment without proper notice, we miss the opportunity to fill those appointment times and other clients miss an opportunity to receive their services. I understand that unfortunate and unforeseen circumstances arise to prevent you from coming such as debilitating sickness, disease or death. However, Mismanaging schedules, changes in work duties, forgetting appointment, etc. will require the cancellation fees. A 24 hours’ notice of appointment cancellation and/or changes in desired service(s) is required to avoid being charged full price of service(s).. You must confirm your appointment when you receive your reminder(email and/or text) to avoid appointment being canceled and charged for full services scheduled. In the event of cancellations received less than 24 hours prior to appointment, late arrivals(10 or more minutes) or no shows, a cancellation fee equal to the reserved service booking will incur.
I understand and agree to the reservation and cancellation policies at Luxe Skin Care and consent to my credit card on file being charged if I fail to give 24 hour notice for appointments scheduled. For full policies please click on terms & policies below to view.
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.
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