Loading...

Waxing Waiver

Please note: waxing does have certain side effects such as skin removal/lifting, redness, swelling, tenderness, bruising, allergic reaction to wax, etc. I have been advised that the service(s) provided to me by Highbrow could have these unfavorable results and if I have any concerns, I will address these with my esthetician, Leanna Inman.

I am aware that certain medications and over the counter products can significantly increase the risk of injury when combined with skin care services and I agree to disclose usage of said medications and products to my esthetician before services can be provided to me. I will advise my esthetician should I use any such medications in the future.

I give permission to my esthetician, Leanna Inman, to perform the waxing services I am requesting and will hold her and Highbrow harmless from any liability that may result from waxing treatments. I agree to adhere to all safety post care including: no peels, tanning, no swimming/spas/hot tubs for 48 hours after waxing; and all home skin care protocols as recommended by my service provider. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have given an accurate account of the questions I have and they have been answered truthfully and completely to the best of my knowledge. I understand the below questions and have had sufficient opportunities for discussion to have any questions answered. I understand the waxing procedures and accept the risks. This waiver and release is effective for any and all visits to Highbrow. 


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Medications and Skin Treatments:
Are you currently taking any of these medications?
Accutane (acne medication)
Adapalene (acne medication)
Alustra (Retin A)
Avage (Acne medication)
Avita (Retin A)
Azelex (Peeling agent)
Clindamycin
Differin (Acne medication)
Doxycycline
Erythromycin
Isotretinoin (like Accutane)
Madifloxicine
Metronidazole
Prednisone
Renova (Retin A)
Retin A (Acne and Anti-aging medication)
Tazarac (Acne medication)
Tazarotene (Tazorac)
Tetracycline
Tretinoin (Retin A)
Have you been on Accutane within the last year?*
No
Yes
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?*
No
Yes
Have you had any skin treatments such as laser resurfacing, chemical peels, or microdermabrasion within the last 7 days?*
No
Yes
Are you using any other skin thinning products and/or drugs that thin the blood?*
No
Yes
Do you currently have a sunburn or have you been in a tanning bed within the last week?*
No
Yes
Are you currently receiving cancer treatment?*
No
Yes
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*

Middle 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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!