Waxing - Client Information & Consent Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Have you used any Alphy Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? Yes No Are you using Resin-a, Renova, or Accutane (an oral form of Resin-a)? Yes No Are you using any other skin thinning products and/or drugs? Yes No Are you exposed to the sun on a daily basis or are you considering spending more tiem in the sun soon? Yes No Do you use a tanning bed? Yes No Are you diabetic? Yes No Are you currently taking medication? If so, please list all (including over the counter drugs/herbal supplements/vitamins etc.) What skin products do you regularly use on your skin? Have you ever been treated for cancer? IF yes, when and what types of therapies were used? Please list any other illness/condition you are currently being treated for by a medical professional Female Clients - When is your next menstrual cycle due to begin? Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. * Acknowledge Consent * 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, Tandi Bergsma, or the salon, Creative Design, responsible for any of my conditions that were present, but not disclosed at the time fo this skin care procedure, which may be affected by the treatment performed today. I agree Electronic Signature * (First and Last Name) Date MM DD YYYY Thank you! Your form has been submitted.
