Client Information And Consent Form: Waxing (Page 2 of 2) in pdf

Contraindications

Caution urged

☐ Broken skin

☐ AHAs, Retin-A, Renova (discontinue use

48 hours prior to treatment)

☐ Inflammation

☐ Diabetes

☐ Suspicious growths

☐ Flat moles

☐ Accutane (last six months)

☐ Phlebitis

☐ Active herpes

☐ Fragile capillaries

Please mark all of the above that apply to you

I understand that, following the waxing procedure, I should:

• Apply a sunblock with an SPF of at least 15

• Avoid use a loofah or other abrasive to the waxed area

• Avoid saunas, steam rooms, Jacuzzis or other heat sources

• Avoid application of Retin- A, Renova, or AHA products for 48 hours

Please note that waxing has certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information 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 and her staff harmless from any liability that may

result from this treatment. I have given an accurate account of the questions asked above including all known allergies or

prescription drugs or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to

minimize or eliminate negative reactions as much as possible.

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 negatives reactions. In the event that I may have

additional questions or concerns regarding my treatment or suggested home products/ 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 paragraphs and that I have had sufficient opportunity for discussion to have any questions

answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose 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 ________________________________________________ Date: ______________________

Client Information And Consent Form: Waxing Page 2