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WAXING CONSENT FORM

 

WE HAVE THE RIGHT TO REFUSE ANYONE.

IF MORE THAN 10 MINUTES LATE YOUR APPOINTMENT WILL BE CANCELED. NO EXCEPTIONS!

 

Waxing does have certain side effects such as skin removal, redness, swelling, tenderness, pustules, acne or folliculitis etc. Any medications including prescriptions, supplements, herbs and change of diet may cause the skin to change for a period of time, which can cause the side effects listed above.

Contraceptives may cause the skin to be sensitive to bruising and or chaffing.

It is very important to understand the changes made with medications, herbs, supplements and life style effect the skin with waxing, which may cause sensitivity during your service and/or after the service performed.

I have read the above information and if I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician at We Wax That! Spa to perform the waxing service and will hold her and We Wax That! Spa harmless of any liability that may result from this treatment.

I have given an accurate account of the questions asked above including all known allergies, prescription medication or products I am currently ingesting or using topically.

I have read and understand the post treatment client instructions at wewxthat.com. 

If I have additional questions or concerns regarding my treatment or suggested home post treatment care, I will consult We Wax That! Spa 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 risk. 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 performed today.

Today's Date: September 21, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
First Participant's Signature*
Second Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Third Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Fourth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Fifth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Sixth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Seventh Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Eighth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Ninth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Tenth Participant's Name

First Name*

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

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

How did you hear about us? Referred by:

Internet Search: (What did you search for? Ex: "waxing," "Best Brazilian in St. Louis")
Have you used any Alpha Hydroxy Acid (AHA) products in the past 48/72 hours?*
No
Yes
Are you using Retin A, Renova, Accutane or Antibiotics ( oral or topical)?*
No
Yes
Are you using any other skin thinning products and/or medications? Oral or Topical?*
No
Yes
Are you currently taking an oral contraceptive or have a contraceptive implants?*
No
Yes
Are you allergic to Coconut and/or Coconut oil?*
No
Yes
May we apply a preventive for ingrown hairs, such as a cream or serum during your waxing service, only if needed?*
No
Yes
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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