Waxing Consent form

Name *

First

Last

Email *

Phone number

Referred by:

Are you prone to experiencing?

Ingrown Hairs
Scarring
Bumps
Hyperpigmentation
Brusing

Have you taken ACCUTANE in the past year?

YES
NO

Are you using RETIN-A, DIFFERIN, OR RENOVA?

YES
NO

Are you taking any medications that make you photosensitive?

YES
NO

ARE you using an ALPHA HYDROXY ACID OR BETA HYDROXY ACID?

YES
NO

Are you diabetic?

YES
NO

Are you currently pregnant?

Are you allergic to anything?

YES
NO

if yes, please describe:

Any other medications?

Do you 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 aesthetician?

Yes
No

Do you understand that with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks?

Yes
No

For Brazilian and/or bikini waxing , do you agree to notify your aesthetician if you are on your menstrual cycle?

Yes
No

Do you understand that some possible side effects include, redness, swelling and pimples, but these are temporary and generally fade within 72 hours.

Yes
No

Photographs relating to my case, may be published and/or republished, either separately or in connection with each other, in professional journals, medical books, social media, skin care magazines, slides, or used for any purpose which he/she may deem proper in the interest of medical education, knowledge, or research, provided, however; it is specifically understood that in any such publication or use I shall not be identified by name( unless given permission).

Agree
Disagree

My signature acknowledges that I have read and agree to receive the treatments or series of treatments listed above and that I will adhere to all of the warnings above.

Date *

Name