Visionary Esthetics Waxing Consent

Name *

First NameLast Name

Date

Phone Number *

Area CodePhone Number

Email *

example@example.com

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

YesNo

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?

YesNo

Are you using any other skin thinning products and/or drugs?

YesNo

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?

YesNo

Do you use a tanning bed?

YesNo

Are you diabetic?

YesNo

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements):

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

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. I confirm I have read the above information and if I have any concerns, I will address these with Visionary Esthetics. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her 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 that Visionary Esthetics will take every precaution to minimize or eliminate negative reactions as much as possible. I understand that I should keep the treated area free of products for 24 hours post-treatment. I am willing to follow recommendations made by Visionary Esthetics 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 my therapist 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 Visionary Esthetics 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.

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