Waxing Consent Form Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail* Have you used any Alpha Hydroxy Acid (AHA) or Glycolic products in the past 48-72 hours?*YesNoAre you using Rentin-A, Renova, or Accutane (an oral form of Retin-A) ?*YesNoAre you using any other skin thinning products and/or drugs?*YesNoAre you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*YesNoDo you use a tanning bed?*YesNoAre you diabetic?*YesNoCurrent MedicationsAre you currently taking medications?*YesNoIf so, please list all (including over the counter drugs/herbal supplements): Medications currently being taken.Click on the plus(+) at the end of the line to add items.Product NamePurposeMorning, Evenings or BothTimes per week? Supplements currently being taken.Product NamePurposeMorning, Evenings or BothTimes per week? Other drugs or supplements currently being taken.Product NamePurposeMorning, Evenings or BothTimes per week? Skin Products Currently UsedWhat skin products do you regularly use on your skin?Skin ProductsClick on the plus(+) at the end of the line to add items.TypeBrandProduct NamePurposeMorning, Evenings or BothTimes per week? Have you ever been treated for cancer?*YesNoWhat type of cancer treatment therapies were usedPlease list any other illness/condition you are currently being treated for by a medical professional.Agreement and DisclaimerPlease note that waxing does have 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 skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless for 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 negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/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 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. SignatureDate Date Format: MM slash DD slash YYYY CAPTCHANameThis field is for validation purposes and should be left unchanged.
