Wax Consent Form

Have you taken Accutane within the past 12 months?*

Yes

If so, provide date of last dose: _________________________________

Are you pregnant, diabetic, or receiving cancer treatment?

Yes

Have you recently received any exfoliating treatments or chemical peels?

Yes

Are you using acne medications (prescribed or over the counter) including: Retin-A, Differin, Tazorac, Atralin, or other retinoids?

Yes

If so, please specify and provide date of last dose: __________________

Are you taking antibiotics, birth control, or hormone replacements?

Yes

If so, please specify and provide date of last dose: __________________

Do you have AIDS, Lupus, or other chronic condition(s) that may compromise the skin barrier?

Yes

If so, please specify:

Do you have any allergies including allergies to wax or latex?

Yes

If so, please specify:

Have you used a tanning bed or experienced prolonged sun exposure within the past 24 hours?

Yes

Do you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins, or any skin sensitivities?

Yes

If so, please specify:

Are you menstruating or about to begin menstruating?

Yes

Procedure Waxing is a procedure to remove unwanted hair from its roots. Hot wax is applied to the skin and then quickly pulled away, taking hairs with it. Side Effects Waxing may cause side effects. The side effects listed here are merely examples and are not intended to be an exhaustive list. Every person is different, and there is no guarantee that you will not experience more severe side effects. The most common side effects include quickly dissipating, mild discomfort when the wax removes hair from its root. Waxing may cause inflammation, welts, hives, skin lifting, and reddening or small breakouts. This is usually not severe and typically will subside within a few days. Please contact us immediately if you experience more severe or long- lasting side effects. Waiver I understand and acknowledge that there are risks involved with the waxing procedure(s), including, but not limited to, those side effects listed above. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby waive _________________________’s liability if such results or complications occur. I further understand that my failure to follow post-procedure instructions may also lead to undesired results, complications or effects and hereby waive _________________________’s liability if such results or complications occur. In consideration for _________________________ performing this procedure(s), I agree that I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure(s) or side effects I may experience after the procedure(s) is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against _________________________, its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of the procedure(s). I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to, and authorize _________________________ to perform, the procedure(s) described above on me.

By typing your full name below you agree to the above terms and conditions.

Parent/Guardian please type your full name if the above client is a minor.

AUTHORIZATION AND CONSENT FOR WAXING

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