Waxing Consent Form

First Name:*

Last Name:*

Birthdate:*

Phone:*

Email:*

5416 Roberts Street, Shawnee, KS 66226 ● 913.441.9090

Do you or are you prone to

Ingrown Hairs?:*

Yes No

Scarring:*

Yes No

Bumps:*

Yes No

Hyperpigmentation:*

Yes No

Bruising:*

Yes No

Allergies:*

Yes No

Have you used any of the following in the last 48-72 hours?

Accutane:*

Yes No

Retin-A:*

Yes No

Alpha-Hydroxy Acid:*

Yes No

Glycolic Acid:*

Yes No

Resorcinol:*

Yes No

Scrub or Peel:*

Yes No

Information:*

I have read the information above and if I had any concerns, I have addressed them with my esthetician.

Permission:*

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 my esthetician will take every precaution to minimize or eliminate any negative reactions.

Consent:*

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 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 preformed today.

Your Signature:*