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Waxing Consent Form
Completion of this form is required prior to your appointment. Submission is your authorization that all is true and accurate.
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Email *
HAVE YOU TAKEN ACCUTANE WITH THE PAST YEAR? *
ARE YOU USING RETIN-A, DIFFERIN, OR RENOVA? *
ARE YOU TAKING ANY MEDICATIONS THAT MAKE YOU PHOTOSENSITIVE? *
DO YOU FREQUENT TANNING BEDS? *
ARE YOU CURRENTLY SUNBURN? *
ARE YOU A DIABETIC *
PLEASE NOTE THE FOLLOWING WARNINGS
***YOU ACCEPT RESPONSIBILITY THAT YOU WILL SHARE IF YOU ARE ON MEDICATIONS OR EXPERIENCE ANY OF THESE CONDITIONS, AS WELL AS ACCEPT RESPONSIBILITY FOR ANY ADVERSE REACTIONS. YOU MAY ALSO CHOOSE TO CHANGE OR CANCEL YOUR APPOINTMENT.***
DO YOU CURRENTLY HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING MEDICAL CONDITIONSTHAT COULD COMPROMISE YOUR SKIN AND/OR SERVICES BEING OFFERED *
Required
IF YOU ARE ON ANY OF THE FOLLOWING MEDICATIONS, YOU CANNOT BE WAXED TODAY. *
Required
YOU MAY EXPERIENCE SKIN SENSITIVITY/THINNING, WHICH CAN RESULR IN SKIN LIFTING, FROM THE FOLLOWING: *
Required
CONSENT AND SIGNATURE:
I UNDERSTAND THAT IF I BEGIN USE, OR ARE CURRENTLY USING, ANY OF THE PRODUCTS LISTED IN THE ABOVE WARNING AND DO NOT INFORM THE ESTHETICIAN PRIOR TO CURRENT OR FUTURE TREATMENTS, I ACCEPT FULL RESPONSIBILITY FOR ANY ADVERSE REACTIONS.

I UNDERSTAND THAT WAXING MAY CAUSE SOME REDNESS BUMPS, SORENESS, AND/OR ITCHING. BY SUBMISSION OF THIS FORM, I AGREE TO THIS STATEMENT.
CLIENT CONSENT 18 AND OVER (TYPE NAME) *
PARENT/GUARDIAN CONSENT UNDER THE AGE OF 18
IN THE FOLLOWING QUESTIONS PLEASE COMPLETE THE ENTIRETY OF THE STATEMENT.
I, (PARENT/GUARDIAN NAME) *
AUTHORIZE (NAME OF MINOR) WAXING TREATMENT ON (DATE) **TYPE STATEMENT BELOW** *
SIGNATURE (TYPED NAME) OF PARENT OF GUARDIAN HERE *
A copy of your responses will be emailed to the address you provided.
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