Waxing Consent Form printable pdf download

WAXING CONSENT FORM

Name: _______________________________________

Date: ___________________________

Address: ______________________________________________________________________________

City, State & Zip: _______________________________

Referred by: ______________________

Phone Number: ________________________________

Email Address: ____________________

I, _____________________________________, give consent to the service provider at The Treatment Room

(print name)

Room to perform the following wax services:

_______________________________________________________________________________________

______ I have not used a scrub, Retin-A, Retinol OTC, take home micro-dermabrasion, glycolic peels, other

peels, exfoliated or tanned in the last 72 hours.

______ I have been off of Accutane for at least twelve (12) months.

______ Some possible side effects include redness, swelling and pimples, but these are temporary and

generally fade within 72 hours.

_______ For Brazilian and/or bikini waxing, I will notify my service provider if I am on my menstrual cycle.

_______ I do not have any open skin lesions or active herpes outbreak (cold sore or genital).

_______ I 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.

_______ 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 am over 18 years of age or I have parental consent co-signed below.

_______ I will call to inform my service provider of any complications or concerns I may have as soon as they

occur.

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 aforementioned statements that I have initialed.

____________________________________

______________

Client Signature

Date

____________________________________

______________

Guardian Signature

Date

____________________________________

______________

Service Provider Signature

Date

We have the right to refuse services for all waxing if proper hygiene is not followed.

For Brazilian and bikini waxes, please use the provided wipe to cleanse area.

Waxing Consent Form