"Waxing Consent Form - the Derma Room"

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WAXING CONSENT FORM
Name: __________________________________________
Address:_________________________________________
City:___________________________ State:_________ ZIP: ___________
Phone (Home): _______________ (Mobile)___________________
E-mail:_______________________________________________________
Please Answer the Following Questions:
1. Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? Yes ( ) No ( )
2. Are you using Retin-A, Renova or Accutane (an oral form of Retina)? Yes ( ) No ( )
3. Are you using any other skin thinning products or drugs? Yes ( ) No ( )
4. Are you exposed to the sun daily or are you considering spending more time in the sun soon? Yes ( ) No ( )
5. Do you use a tanning bed? Yes ( ) No ( )
6. Are you diabetic? Yes ( ) No ( )
7. Are you currently taking medication? Yes ( ) No ( )
If “yes”, please list all, including over-the-counter drugs and herbal supplements:
______________________________________________________________________
______________________________________________________________________
8. What skin care products do you regularly use on your skin?
___________________________________________________________________________________________________________
_________________________________
WAXING AGREEMENT/ ACKNOWLEDGEMENT
I have completed the above to the best of my knowledge and if I have any concerns, I will address these with my esthetician. I give
permission to my esthetician to perform the waxing procedure we have discussed and will hold her and her staff harmless from all
liability that may result from the treatment. I have given an accurate account of all information including known allergies, prescription
drugs or products I am currently ingesting or using topically.
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 and that I have had sufficient opportunity to have any questions answered. I understand the procedure
and accept the risks. I do not hold the esthetician, who’s 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.
Client name (printed):____________________________________________
Client name (signature): __________________________________________
Date:________________________
Esthetician Signature: ________________________________________
Date: _______________________
WAXING CONSENT FORM
Name: __________________________________________
Address:_________________________________________
City:___________________________ State:_________ ZIP: ___________
Phone (Home): _______________ (Mobile)___________________
E-mail:_______________________________________________________
Please Answer the Following Questions:
1. Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? Yes ( ) No ( )
2. Are you using Retin-A, Renova or Accutane (an oral form of Retina)? Yes ( ) No ( )
3. Are you using any other skin thinning products or drugs? Yes ( ) No ( )
4. Are you exposed to the sun daily or are you considering spending more time in the sun soon? Yes ( ) No ( )
5. Do you use a tanning bed? Yes ( ) No ( )
6. Are you diabetic? Yes ( ) No ( )
7. Are you currently taking medication? Yes ( ) No ( )
If “yes”, please list all, including over-the-counter drugs and herbal supplements:
______________________________________________________________________
______________________________________________________________________
8. What skin care products do you regularly use on your skin?
___________________________________________________________________________________________________________
_________________________________
WAXING AGREEMENT/ ACKNOWLEDGEMENT
I have completed the above to the best of my knowledge and if I have any concerns, I will address these with my esthetician. I give
permission to my esthetician to perform the waxing procedure we have discussed and will hold her and her staff harmless from all
liability that may result from the treatment. I have given an accurate account of all information including known allergies, prescription
drugs or products I am currently ingesting or using topically.
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 and that I have had sufficient opportunity to have any questions answered. I understand the procedure
and accept the risks. I do not hold the esthetician, who’s 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.
Client name (printed):____________________________________________
Client name (signature): __________________________________________
Date:________________________
Esthetician Signature: ________________________________________
Date: _______________________