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Please answer all questions completely & truthfully.


I hereby consent to this procedure allowing Najla Keserovic | House of Wax Studios to perform Microchanneling on my skin, and to apply topical preparations as determined necessary. I understand that Microchanneling is non-ablative skin rejuvenation & involves the creation of perforations in my skin to promote healing responses to rejuvenate my skin. I understand that the procedure is performed with an automatic perforating device and that clinical results may vary. I understand there is a possibility of short-term effects such as reddening, peeling, scabbing, temporary bruising and temporary discoloration of the skin, as well as rare side effects such as infection & scarring. These effects have been fully explained to me. Clinical results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post treatment instructions.

I understand that the Microchanneling treatment may involve a series of treatments and the fee structure has been fully explained to me.

I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.

I confirm that I am not pregnant at this time. I also have completed a medical history checklist and been informed about what I must do and “not do” before, during and after the procedure.

I understand that fever blisters may occur on the lips following lip procedures in individuals prone to this problem. Pre-treating the area with prescription-strength anti-viral medication is advised. Secondary infection in the area of the procedure is rare if properly cared for but may occasionally occur.

I consent and authorize the use of any photographs of me for the purposes of marketing and education:

I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this consent form.

I furthermore indemnify the authorized person herein, and hold harmless from any and all claims, demands, liabilities, judgments, costs and expenses arising out of any claims relating to the procedure authorized herein.





First Your Name

First Name*

Last Name*

Phone*
First Your Date of Birth*
First Your Signature*
Second Your Name

First Name*

Last Name*

Phone*
Second Your Date of Birth*
Third Your Name

First Name*

Last Name*

Phone*
Third Your Date of Birth*
Fourth Your Name

First Name*

Last Name*

Phone*
Fourth Your Date of Birth*
Fifth Your Name

First Name*

Last Name*

Phone*
Fifth Your Date of Birth*
Sixth Your Name

First Name*

Last Name*

Phone*
Sixth Your Date of Birth*
Seventh Your Name

First Name*

Last Name*

Phone*
Seventh Your Date of Birth*
Eighth Your Name

First Name*

Last Name*

Phone*
Eighth Your Date of Birth*
Ninth Your Name

First Name*

Last Name*

Phone*
Ninth Your Date of Birth*
Tenth Your Name

First Name*

Last Name*

Phone*
Tenth Your Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Client Questionnaire

Please enter today's date. *
Are you currently pregnant or breastfeeding?*
No
Yes

Please list any allergies you have.

Please describe your skin type. *

Please list your skin concerns & goals. *

Please describe your current skin care routine (within 60 days) listing products etc. frequency of use. *

Have you ever had a facial before? If so, please list what you gained from it or if the results met your expectations. Please include number & frequency of facials. *

Please list any cosmetic or aesthetic work you've had done on your face & include any negative reactions. This may include waxing, injections, surgeries, facials, lasers etc., *

Please list any additional comments, questions, concerns etc., regarding our treatment or your skin history. *

Have you had any negative reactions with products you've used at home? *

Please list any medications you are on if any. If none please type N/A *
MEDICAL HISTORY Have you experienced any of the following health conditions in the PAST or PRESENT? Check all that apply.
Autoimmune DIsorder
Arthritis
Asthma
Cancer/System Disease
Cold Sores
Diabetes
Hypertension
HIV/AIDS
Hormonal Imbalances
Epilepsy
Lupus
Skin Conditions/Diseases
Staff Infection/MRSA
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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