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Waxing Consent Form
Fill Out Form Below
Consent Form
Name
Address
Phone Number
Email
How often do you have waxing done?
Have you ever had a reaction to a waxing service? Yes or No? If yes, please describe:
Do you have any tendencies to any of the following:
Ingrown Hair
Scarring
Bumps
Hyperpigmentation
Bruising
Have you received Botox treatments in the last 72 hours?
Yes
No
Have you been or will you be in the sun and/or tanning bed within 24 hours of this treatment?
Yes
No
Are you using or taking:
Accutane of Tetracycline
Retinoids such as Retin-A, Renova or Diferin
AHA/Alpha-Hydroxy Acid
BHA/Beta-Hydroxy Acid
Glycolic Acid
Any other medications, please specify below
Are you currently pregnant?
Yes
No
Do you have Diabetes, Phlebitis or any skin irritations?
Yes
No
Is your skin dry?
Yes
No
I FULLY ACKNOWLEDGE
I have been advised the service(s) provided to me by this salon could have unfavorable results including, but not limited to: allergic reaction, irritation, burning, redness, soreness, etc. I am aware that certain medications and over-the-counter products can significantly increase the risk of injury when combined with skin care services. I understand that Bare Beauty Wax does not recommend skin care services for customers using Retin-A, Accutane and products contacting alpha hydroxyl, or any other skin thinning treatments. I hereby confirm that I am not using any medications that may cause or contribute to such injury/reaction, and I will advise my esthetician should I use any such medications in the future. I understand there are often inherent risks associated with skin care services, and I agree that as a condition of providing these services on an on going basis, I will not hold Bare Beauty Wax and Esthetician liable.
Signature accepted, submit form to complete.
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Are you allergic to anything? Yes or No? If yes, please describe: