Waxing Consultation Form

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Birch Skin Studio Waxing Consultation Form
Client Name ___________________________________________________________________________________________
If under 18, please provide your age _______
Waxing certain areas can be uncomfortable. We attempt to minimize discomfort by waxing with a
professional technique. In addition, there are also steps that can be taken before the procedure, such
as taking ibuprofen or other oral analgesic before the procedure. Please tell us if there is anything we
can do to make your waxing experience more comfortable.
________________________________________________________________________________________________________
Are you currently taking Accutane? Yes No
Are you currently using Retin-A / Tretinoin / Renova / Acne Medicine? Yes No
Have you ever been waxed before today? Yes No
Have been diagnosed with diabetes? Yes No
Do you have any known allergies? Yes No
Description of allergies
________________________________________________________________________________________________________
Possible complications with waxing procedures:
Sensitive skin can burn from waxing procedures.
Accutane and Retin-A or Tretinoin are drying to the skin, therefore, waxing may lead to removal of
skin, which may cause scarring.
Waxing over sunburned or very tanned skin may lead to removal of the skin, which may cause
scarring.
Diabetics have a very hard time healing when a wound or lesion occurs to the skin, as the immune
system is unable to function fully to fighting bacteria.
Allergies to any of the product ingredients used in waxing may cause severe allergic reaction.
I confirm (to the best of my knowledge) that the information I have provided is accurate and
complete. I have not withheld any information that may be relevant to my treatment and/or the
results thereof. I am aware that there are often inherent risks associated with skin care services
including waxing procedures, and that the services I am about to receive could have unfavorable
results including, but not limited to: allergic reaction, irritation, burning, redness, scarring, soreness,
etc. By signing below, I further agree that I will not hold Birch Skin Studio or any of its employees responsible
should there be any unfavorable outcome or result.
Signature:________________________________________________________Date:________________________________
Client If under 18, Parent signature
*********************************************************************************
Parent or Guardian Consent (Must be completed for clients under the age of 18)
In consideration of (“Minor”)_______________________(print minor’s name) being permitted by
Birch Skin Studio to participate in its services including but not limited to, skin care
services. I further agree to indemnify and hold harmless Birch Skin Studio from any
and all claims which are brought by, or on behalf or Minor, and which are in any way connected with
such services by Minor.
Signature of Parent or Guardian: ________________________________________________________________________
Print Name: ______________________________________________________ Date:________________________________

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