WAXING CONSENT FORM

(YOUR FORM WILL ONLY BE SAVED AFTER BOOKING YOUR APPOINTMENT)*

Name

First Name

Last Name

Phone

(###)

###

####

Today's Date

YYYY

I am informing my technician of any of the following contraindicated conditions:

(please read and check all that apply)

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

Current use of Retin-a, Renova or Accutane (an oral form of Retin-a)

Current use of any skin thinning products and/or drugs?

Have you recently spent time in the sun and/or tanning bed?

Are you a diabetic?

Allergies or sensitivity to instruments, waxes, cleaners or eye gel pads.

None

Are you currently taking medications?

If so, please list all (including OTC drugs/herbal supplements.)

Have you ever been treated for cancer?

Yes

If yes, what treatment was administered?

List skin products regularly used on your skin.

When is your next menstrual cycle due to begin?

Always allow five dates time before 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 are it is completed?

Acknowledgment + Waiver

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 them with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discuses 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 prescriptions drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to 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 discloser, 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 who performed my service 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.

Digital Signature

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepesentation of my health history.

WAXING CONSENT FORM

(YOUR FORM WILL ONLY BE SAVED AFTER BOOKING YOUR APPOINTMENT)*

Hours of Operation

BR Brows + Beauty

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