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 ​Waxing Consent 

 I Have not used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? 

I have not used Retin-a in the last 5-7 days.

i have not used Renova or Accutane (an oral form of Retin-a) in the last 6 months.

I am not using any other skin thinning products and/or drugs.

I agree to use sunprotection for the next 3-5 days after treatment or avoid long period of sun exposure.

 

I am not Diabetic.

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. I have read the above information and if I have any concerns, I will address these with my HBC Estheticain . I give permission to my esthetician to perform the waxing procedure we have discussed and will hold her 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 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 negative reactions as much as possible. I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician 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 esthetician 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 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.

First Client Name

First Name*

Last Name*

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

First Name*

Last Name*

Phone*
Second Client Date of Birth*
Third Client Name

First Name*

Last Name*

Phone*
Third Client Date of Birth*
Fourth Client Name

First Name*

Last Name*

Phone*
Fourth Client Date of Birth*
Fifth Client Name

First Name*

Last Name*

Phone*
Fifth Client Date of Birth*
Sixth Client Name

First Name*

Last Name*

Phone*
Sixth Client Date of Birth*
Seventh Client Name

First Name*

Last Name*

Phone*
Seventh Client Date of Birth*
Eighth Client Name

First Name*

Last Name*

Phone*
Eighth Client Date of Birth*
Ninth Client Name

First Name*

Last Name*

Phone*
Ninth Client Date of Birth*
Tenth Client Name

First Name*

Last Name*

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

Email*

Confirm Email*
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Are you currently taking any medications?
Click to customize question*
No
Yes

If yes please list. *
Do you currently have any medical conditions (ie Herpes, HIV, Hepatitis, contagious skin conditions etc)
Click to customize question*
No
Yes

If yes please state. *
Please list any allergies.
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.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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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