Consent Form Waxing - Rejuvenation Spa Of Alpharetta printable pdf download

REJUVENATION SPA OF ALPHARETTA

Christi Stowers Enterprises

1380 Upper Hembree Road, Roswell, GA 30076

Consent Form – Waxing

Patient Name:__________________________________________ Date:____________________

Have you used any alpha Hydroxy Acid (AHA) or glycolic products in the 48-72 hours?

_________ no _________ yes

Are you using Retin-a, Renova, or Accutane (an oral form of Retin-a)?

_________ no _________ yes

Are you using any other skin thinning products and/or photo-sensitive drugs? If so, please list

medications here:

_______________________________________________________________________________

______________________________________

Are you exposed to direct sun on a daily basis, or do you plan on spending more time in the sun

soon?

_________ no _________ yes

Do you use a tanning bed?

_________ no _________ yes

I have read the above information and if I have any concerns, I will address these with my skin

therapist. I give permission to my therapist to perform the waxing procedure we have discussed

and will hold her 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 agree that this constitute 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.

Patient Signature:_________________________________________ Date:____________________

08/08/17

Consent Form Waxing - Rejuvenation Spa Of Alpharetta