Wax Consultation & Consent Form

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Name *

First and last name

Phone Number *

Check the following that apply: *

Do you take isotretinoin?

Do you take tetracycline?

Do you use products that contain retinoic acid?

Do you use products that contain AHA glycolic acid?

Do you use products that contain hydroquinone?

Have you had a recent chemical peel or advanced exfoliation?

Any recent surgery?

Any skin cancer?

Are you pregnant?

Do you have any moles, warts, abrasions, skin irritations, or skin inflammations in the area being waxed?

Have you been exposed to any tanning methods within the past 24 hours?

Have you taken any blood thinners, aspirin or any anticoagulating medication within the last 24 hours?

Have you ever suffered from any adverse reaction from waxing previously?

None of the above.

Required

Any allergies? If so please list below. *

Are you on any medications? If so please list below. *

Please read and accept our terms of service by checking the boxes. *

I am over the age of 18, or I have parental consent co-signed below.

I have not used a scrub, Retin-A, Retinol OTC, take home micro dermabrasion, glycolic peels, other peels, exfoliated or tanned in the past 72 hours.

I have not taken any Accutane for at least 12 months.

I do not have any open skin lesions or active herpes outbreak. (Cold sore or genital)

For Brazilian and/or Bikini wax; I will inform my esthetician if I am in my cycle.

I am aware there may be possible, temporary side effects such as redness, swelling and pimples, that generally fade within 72 hrs.

I understand with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.

I agree to adhere to all safety post care including: no peels, tanning or wet room services, no swimming/spas/ hot tubs for 24 hours after sugaring, and all home skin care protocols as recommended by my service provider.

I will call to inform my service provider of any complications or concerns I may have as soon as they occur.

Required

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