Waxing Consent Form printable pdf download

Waxing Consent Form

Name _______________________________

Date ___________________

Birth Date: _________________________

Email__________________________________

Address:______________________________________________________________________

Phone: _________________________________

Cell Phone

Provider:__________________

How did you hear about us? ___________________________________________________

Have you had waxing service before?

Yes ____

No ____

Do you have any pine allergies?

Yes ____

No ____

Have you had recent sun exposure?

Yes ____

No ____

When is the last time you exfoliated your face? ____________________________________

Date of last peel or microdermabrasion: __________________________________________

What medications are you taking? _______________________________________________

_____________________________________________________________________________

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.

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 Body by Shae or its affiliates or any of its

employees responsible should there be any unfavorable outcome or result.

Signature _______________________________________

Waxing Consent Form