Loading...

Please note that waxing has certain side effects such as skin removal, redness, swelling, tenderness, scabbing, scaring, hyperpigmentation, and/or pimpels etc. If you have any concerns please address them with your esthetician as soon as possible. 

New use of any of the medications listed in the Waxing Questionnaire below increases the possibility of a reaction. Please inform the esthetician if you have begun taking any new medications since your last session.

Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. The most common occurrence of this is in a Brazilian bikini wax. 

Post Treatment Home Care Instructions 

  • Apply sunblock with SPF of at least 15
  • Avoid using 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 following waxing
    I Agree
     

I have read the above information and if I have any concerns, I will address them with my esthetician. I give permission to my esthetician to perform the waxing procedure we have discussed and will hold her and Essentials Massage & Facial Spa of Pasadena harmless from any liability that may result from this treatment. I will give an accurate account of the questions asked in the consent form below 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 the 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/posttreatment care, I will consult my 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, who performs the service, 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. 

May 22, 2019

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Third Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Fourth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Fifth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Sixth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Seventh Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Eighth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Ninth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Tenth Client's Name

First Name*

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

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
No
Yes
Parent or Guardian's Email Address

Email*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
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*
Parent or Guardian's Information

What body part(s) are we waxing today? *

When did you last shave? *
Contraindication for waxing. Please select any that apply to you. *
None
Broken Skin
Inflammation
Suspicious Growths
Accutane (last 6 months)
Active Herpes
Do you have or are you prone to any of the below? Check all that apply. *
None
Bruising
Bumps
Hyperpigmentation
Ingrown Hairs
Scaring
Allergies. If yes, please list below.
Have you used any of the following in the last 48-72 hours?
Accutane
Retin-A
Glycolic Acid
Resorcinol
Scrub or Peel
Alpha-hydroxy Acid
Have you used other skin thinning medication? If yes, please list below.*
No
Yes
Do you use a tanning bed?*
No
Yes
Are you diabetic?*
No
Yes
Have you ever been treated for cancer?*
No
Yes
Any other illness/condition you are presently being treated for by a medical professional? If yes, please explain below.*
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver