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Hair Removal [Sugaring/Waxing] Client Intake and Consent Form
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Full Name *
Street Address *
City *
State *
Zip Code *
Mobile Number *
Home Number
Birthday *
Gender *
Referred By
Are you under 18 years old? [You must have a parent present for treatment if under 18] *
Have you ever been waxed or sugared before today? *
By checking this box, I agree I have NOT used Accutane at least 6 months. *
Required
Have you used any of the following in the last 48-72 hours: Retin-A, Retinol OTC, Tretinoin, Renova, a scrub, take home micro-dermabrasion, Alpha Hydroxy Acid (AHA) or glycolic products such as glycolic peels, other peels, exfoliated, or tanned? *
If yes, which one(s)?
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? *
Are you using any other skin thinning products and/or prescription/over-the-counter drugs? *
If yes, please list other skin thinning products and/or prescription/over-the-counter drugs.
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon? *
Do you use a tanning bed? *
Are you diabetic? *
Do you have any known allergies? *
If yes, describe the types of allergies you have.
What skin products do you regularly use on your skin? *
Have you ever been treated for cancer? *
If yes, when and what types of therapies were used?
Are you using any other blood thinners, antibiotics, hormone-replacement, therapies? *
If yes, which one?
Please list any other illness/condition you are currently being treated for by a medical professional.
Female clients only: When is your next menstrual cycle due to begin? All others, write "N/A" (Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.)
What type of hair removal are you here for, and which part(s) of the body? *
Please read and sign the following information about contradictions and agreement. Possible Complications with waxing/sugaring procedures: All hair removal including waxing/sugaring certain areas can be uncomfortable. We attempt to minimize discomfort with a professional technique. In addition, there are also steps that can be taken before the procedure, such as taking ibuprofen or other oral analgesics before the procedure. Please tell us if there is anything we can do to make your waxing experience more comfortable. Accutane and Retin-A or Tretinoin are drying to the skin, therefore, waxing/sugaring may lead to removal of skin, which may cause scarring. Waxing/Sugaring over sunburned or very tanned skin may lead to removal of the skin, which may cause scarring. Do not use wax hair removers, perform dermabrasion, or laser skin treatments while you are taking Accutane and for at least 6 months after you stop taking it. Scarring may result. Anyone showing signs of redness, rash, open and/or abraded skin, an active lesion of Herpes, Simplex I or II, sunburn (either from natural sun exposure or a tanning bed), psoriasis or eczema cannot receive waxing/sugaring services. Regarding Herpes, Simplex, Types I and II, anyone with a history of Herpes, Simplex I or II has been advised that waxing/sugaring services may cause an outbreak to re-surface. 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. Allergies to any of the product ingredients used in waxing may cause severe allergic reaction. We have the right to refuse services for all waxing/sugaring if proper hygiene is not followed. For Brazilian and bikini waxes/sugaring, please use the provided wipe to cleanse the area. I will notify The MJ Treatment Spa & Wellness if I am on my menstrual cycle. I understand that sensitive skin can have side effects such as burning or skin removal from waxing/sugaring procedures. Some other possible side effects include redness, swelling, and pimples, but these are temporary and generally fade within 72 hours. I do not have any open skin lesions or active herpes outbreak (cold sore or genital)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 skincare services including waxing/sugaring 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 The MJ Treatment Spa & Wellness, its owner, its affiliates, or any of its employees responsible should there be any unfavorable outcome or result. 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/sugaring 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 have read and understood 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 that with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. 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. I agree to adhere to all safety post-care including no peels, tanning or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skincare protocols as recommended by my service provider. I have agreed to submit this form by electronic means. By signing this application electronically, I give consent to treatment and that I certify that all the information I have provided to be accurate. (Type your full name after typing "/s/". Example: /s/ Jane Doe ) *
I am over 18 years of age or I have parental consent co-signed below. For Parent: (Must be completed for clients under the age of 18) In consideration of the client “Minor” (named below) being permitted by The MJ Treatment Spa & Wellness to participate in its services including but not limited to, skincare services, including hair removal (sugaring/waxing). I further agree to indemnify and hold harmless The MJ Treatment Spa & Wellness, its professional esthetician, and affiliates from any and all claims which are brought by, or on behalf of Minor, and which are in any way connected with such services by Minor. My signature acknowledges that I have read and agree to receive the treatments or series of treatments.  (Type your full name after typing "/s/". Example: /s/ Jane Doe ) *
Client's Parent's e-Signature below:  (Type your full name after typing "/s/". Example: /s/ Jane Doe )
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