Waxing Consent Form printable pdf download

Waxing Consent Form

Name (print): _______________________________________________________________________

Address: ___________________________________________________________________________

City: ________________________

State: _____

Zip Code: ___________

Home Phone: _________________ Work: ____________________ Cell: __________________

Email Address: __________________________ Referred By: __________________________

Date of Birth: ____________________ Gender: ( )M ( )F

Do you have or are you prone to:

Yes

Ingrown hairs

( ) Y

( ) N

Scarring

( ) Y

( ) N

Bumps

( ) Y

( ) N

Hyper-pigmentation

( ) Y

( ) N

Bruising

( ) Y

( ) N

Allergies**

( ) Y

( ) N

Are you diabetic?

( ) Y

( ) N

Have you been treated for cancer?

( ) Y

( ) N

Do you have skin lesions

( ) Y

( ) N

Do you have an active herpes outbreak

( ) Y

( ) N

**If yes, please list: ________________________________________________________________

Any other illness /condition you are presently being treated for by a

medical professional? ___________________________________________________________

_____________________________________________________________________________________

Have you used any of the following in the last 48 -72 hours:

Yes

Accutane

( ) Y

( ) N

Retin-A

( ) Y

( ) N

Alpha-hydroxy acid

( ) Y

( ) N

Glycolic acid

( ) Y

( ) N

Resorcinol

( ) Y

( ) N

Scrub or peel

( ) Y

( ) N

Have you used other skin thinning medications? ( ) Y ( ) N

If yes, please list: __________________________________________________________________

Do you use a tanning bed? ( ) Y ( ) N

Please Note:

New use of any of the medications listed above increases the possibility of a reaction. Please

inform the esthetician if you have begun taking any new medications since your last session.

Waxing does have certain side effects including, but not limited to, skin removal, redness,

scabbing, bruising, scarring, swelling, tenderness, hyper pigmentation, flaking, and/or

pimples.

Waxing of soft tissue can cause the skin to tear.

We recommend no peels, tanning and wet room services for 72 hours after waxing treatment.

I have read all the above information and if I had any concerns, I have addressed them with my

esthetician. I give permission to my technician to perform the services we have talked about and

will hold him/her harmless from any liability that may result from this treatment. I have given

an accurate account of all questions asked above.

I understand my esthetician will take every precaution to minimize or eliminate any negative

reactions. I certify that I have read and fully understand the procedure and the risks, and will

not hold the esthetician or establishment of performed services liable for any conditions

that may occur after service is rendered.

Client signature: _____________________________________

Date: ___________________________________

Zonolite Hair Studio

Waxing Consent Form

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