Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Have you used any AHA, Glycolic Products, Retin-A, Renova, Accutane, Blood Thinners, Omega Oils, (or an oral form of Retin-A) in the last 72 hours? *Note: you must stop using these products at least 72 hours before your waxing appointment. *

Yes

No

Are you using any skin thinning products or medications? *

Yes

No

Are you exposed to the sun on a daily basis, planning to spend more time in the sun soon, or using a tanning bed? *

Yes

No

Are you a diabetic? *

Yes

No

Electronic Signature *

First Name

Last Name

Do you agree to the terms below? *

Please 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. l give permission to my therapist to perform the waxing 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 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, whose 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.

I have read and agree to these terms