Waxing Consent Form printable pdf download

Waxing Consent Form

Name: ________________________________________________

Date: ___________________

Address: _____________________________________________________________

City: ___________________ State: _________ Zip Code: _____________

Phone Number: _______________________________

Email Address: ____________________________________

Referred By: ________________________________

I, _________________________________ give consent to Serenity Day Spa 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. ________ (Initial)

I have been off Accutane for at least 12 months. ________ (Initial)

Some possible side effects include redness, swelling, and pimples, but are temporary and generally fade

within 72 hours. ________(Initial)

Are you on your menstrual cycle? Yes or no? ________

I do not have any open skin lesions, active herpes outbreak (cold or genital). ________ (Initial)

I understand that with treatment certain risks are involved and that any complications or side effects from

known or un-known causes could occur. I freely assume these risks. ________ (Initial)

I agree to adhere to all safety post care including: no peels, tanning, or wet room services for 72 hours to

one week and all home skin care protocols as recommended by Serenity Day Spa ________ (Initial)

I am over 18 years of age or I have a parental consent co-signed below. ________ (Initial)

I will call to inform Serenity Day Spa of any complications or concerns I may have as soon as they occur.

________ (Initial)

*My signature acknowledges that I have read and agree to receive the following treatments or series of

treatments listed above and that I adhere to all the above statements I have initialed.

Client Signature: _____________________________________

Date: _________________

Witness or Parent Signature: _______________________________

Date: _________________

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

Please c leanse b efore B razilian a nd B ikini w axes. T hank y ou.

Date o f

Service:

Client

Initial:

Waxing Consent Form