Microsoft word - client information and consent form-waxing.docx

CLIENT INFORMATION AND CONSENT FORM: WAXING Name: _______________________________________ Date of Consultation: ______________________ Address: _____________________________________________________________________________ City: __________________________________________________ State: __________ Zip: ___________ Home: (_____)______________________________ Cel : (_____)________________________________ E-mail: ____________________________________ Date of birth: ________________________________ Known al ergies: ____________________________ Medication: _________________________________ How did you find out about us? Referral / Internet / Other: _____________________________________ If referred by someone, please give his/her name: _____________________________________________ Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past week? Yes / No Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? Yes / No Are you using any blood/skin thinning products and/or drugs? Yes / No Are you exposed to the sun daily or are you considering spending more time in the sun soon? Yes / No Do you use tanning bed? Yes / No. If yes, last time?: _______________________________________ Have you ever had any adverse reactions to waxing? _______ If yes, please explain: _________________ _____________________________________________________________________________________ Have you ever been treated for cancer? If yes, when and what types of therapies were used? __________ _____________________________________________________________________________________ Please list any other il ness/condition you are currently being treated for by a medical professional: ______ _____________________________________________________________________________________ What is your menstrual cycle due date? _____________________ (Always al ow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after is completed). Please mark al of the above that apply to you I understand that, fol owing the waxing procedure, I should: • Apply a sunblock with an SPF of at least 15 • Avoid use a loofah or other abrasive to the waxed area • Avoid saunas, steam rooms, Jacuzzis or other heat sources • Avoid application of Retin- A, Renova, or AHA products for 48 hours Please note that waxing has certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and if I have any concerns, I wil address these with my esthetician. I give permission to my esthetician to perform the waxing procedure we have discussed and wil hold 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 al known al ergies or prescription drugs or products I am currently ingesting or using topical y. I understand my esthetician wil 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 wil ing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negatives reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home products/ post-treatment care, I wil consult the esthetician immediately. I agree that this constitutes ful disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and ful y 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, whose signature appears below, 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. Client Name (printed) ___________________________________________________________________ Client Name (signature) ______________________________________ Date: ______________________ Esthetician ________________________________________________ Date: ______________________

Source: http://www.flawlesswaxnspa.com/_/docs/waxing-consent-form.pdf