Waxing Consent Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Under 18 years of age?*

YesNo

Waxing certain areas can be uncomfortable. We will always attempt to minimize discomfort. You may take an ibuprofen or another oral analgesic before your procedure. This may help diminish the discomfort. Please tell us if there is anything, we can do to make your waxing experience more comfortable.

*For body waxing please be sure to have at least a half inch of hair growth.

Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?*

YesNo

Have you used Retin-A, Renova, or Accutane within the past year? If so, when?*

Are you using any other skin thinning products and/or drugs that thin the blood?*

YesNo

Do you use tanning beds and/or are exposed to the sun on a regular basis?*

YesNo

Are you currently taking any medications? If so, please list.*

Please list any illness/conditions which you are currently being treated for by a medical professional.

Do you have any open skin lesions?*

YesNo

Do you have any allergies? If so, please list.*

Accutane and Retin-A or Tretinoin are drying to the skin, therefore waxing may lead to the removal, irritation or burning of the skin. This may cause scarring. Individuals with compromised immune systems may experience a difficult time healing when a wound or lesion occurs to the skin. Allergies to any of the product ingredients used in waxing may cause a severe allergic reaction.

I confirm (to the best of my knowledge) that the information I have provided is accurate and complete. I have not withheld any information that may be relevant to my treatment and/or the results. I am aware that there are often inherent risks associated with skin care and waxing services. Unfavorable results may include allergic reaction, irritation, burning, redness, scarring. By signing below, I agree that I will not hold harmless Elizabeth Jacob Spa & Salon and/or any of its employees responsible for an unfavorable result.

Signature*