WAX CONSENT FORM Name * First Name Last Name Email * Phone * (###) ### #### Have you used products with Alpha Hydroxy Acid (AHA) or Glycolics in the past 24-48 hours? * Yes No Are you using Accutane, Tretinoin, Retin-A or other acne medications (Oral or Topical)? * Yes No Do you sunbathe or use tanning beds? * Yes No Are you currently taking any medications? * Do you have any allergies? * Please list any medical illnesses/conditions you are currently being treated for. * 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. I 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. * Thank you!
