Waxing Consent Form

Name*

First NameLast Name

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Age?*

How did you hear about me?*

Have you ever had a wax? If so, when was the last time you had a wax?*

Have you ever had a wax?blanks field. Please add appropriate blank fields and text.

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

YesNo

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? If so, when?*

Are you using any other skin thinning products and/or drugs that thin the blood?*

YesNo

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

YesNo

Do you use a tanning bed?*

YesNo

Are you diabetic?*

YesNo

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements): (N/A if not applicable)*

What skin products do you regularly use on your skin?*

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

Please list any illness/conditions which you are currently being treated for by a medical professional. *

Do you have any open skin lesions?*

YesNo

Do you have any allergies? If so, please list.*

(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.)*

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. and anyone showing signs of any irritation or similar problems cannot receive waxing services. Anyone having just received a microdermabrasion treatment or an acid peel cannot receive waxing services to the same area. Anyone with a history of HSV I or II should be aware that waxing services may cause outbreak. 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 72 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.*

Initials

Reservation & Cancellation Policy for all current and future appointments: a valid credit card is required for all appointments. In the event of cancellations received less than 48 hours prior to appointment, a cancellation fee equal to the reserved service booking will incur. Under 48 hrs = 50% of scheduled service, under 24 hrs or no show = 100% of scheduled service. After 3 missed/rescheduled appointments, full payment for any services will be required in advance.*

I understand the reservation and cancellation policies at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged if I fail to give 48 hour notice for appointments scheduled. Pure Skin Makeup and Skincare Studio reserves the right to charge fees to credit card on file or invoice for missed appointments or late cancellations.

Late Arrival: Should you be running late, please call or text the studio immediately. If you are 15 minutes late to any appointment your appointment will be cancelled and charged 50% of all services booked.*

I understand the late arrival policies at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged.

Sick Policy : In an effort to maintain a healthy environment, we ask that if you are sick or anyone in your immediate family (which includes a cold, a fever, the flu, etc.) or have the onset of symptoms of an illness that you reschedule your appointment within 48 hours. If you arrive for your appointment with symptoms of an illness, you will be asked to reschedule your appointment and will be charged 100% for your service. Do not come to the studio sick, we will not charge a fee if you cancel your appointment due to illness, however not rescheduling, not showing up or showing up sick will incur 100% of your services. **

I understand the sick policy at Pure Skin Makeup & Skincare Studio and consent to my credit card on file being charged.

Signature*

Date:*