Waxing Consent Form printable pdf download

WAXING CONSENT FORM

Name: __________________________________________

Address:_________________________________________

City:___________________________ State:_________ ZIP: ___________

Phone (Home): _______________ (Mobile)___________________

E-mail:_______________________________________________________

Please Answer the Following Questions:

1. Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? Yes ( ) No ( )

2. Are you using Retin-A, Renova or Accutane (an oral form of Retina)? Yes ( ) No ( )

3. Are you using any other skin thinning products or drugs? Yes ( ) No ( )

4. Are you exposed to the sun daily or are you considering spending more time in the sun soon? Yes ( ) No ( )

5. Do you use a tanning bed? Yes ( ) No ( )

6. Are you diabetic? Yes ( ) No ( )

7. Are you currently taking medication? Yes ( ) No ( )

If “yes”, please list all, including over-the-counter drugs and herbal supplements:

______________________________________________________________________

8. What skin care products do you regularly use on your skin?

___________________________________________________________________________________________________________

_________________________________

WAXING AGREEMENT/ ACKNOWLEDGEMENT

I have completed the above to the best of my knowledge 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 and her staff harmless from all

liability that may result from the treatment. I have given an accurate account of all information including known allergies, prescription

drugs or products I am currently ingesting or using topically.

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 disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read

and fully understand the above and that I have had sufficient opportunity to have any questions answered. I understand the procedure

and accept the risks. I do not hold the esthetician, who’s signature appears below, 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.

Client name (printed):____________________________________________

Client name (signature): __________________________________________

Date:________________________

Esthetician Signature: ________________________________________

Date: _______________________

Waxing Consent Form