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Facial Wax Consent Form

Personal Agreement: I will let my technition know if I have any of the following:

TAKEN ACCUTANE WITHIN THE PAST YEAR.

USING RETIN- A, DIFFRIN, OR RENOVA

TAKING ANY MEDICATIONS THAT MAKE YOU PHOTOSENSITIVE.

FREQUENT TANNING BEDS.

CURRENTLY SUNBURNED.

DIABETIC.

PREGNANT.

I DO NOT CURRENTLY HAVE OR HAVE HAD ANY OF THE FOLLOWING CONDITIONS THAT COULD COMPORMISE YOUR SKIN AND/ OR SERVICES BEING OFFERED?: AIDS/HIV, HEPATITIS, ECZEMA/PSORIASIS, HERPES, CANCER, COLD SORES

**PLEASE READ THE FOLLOWING WARNINGS**

IF YOU ARE USING ANY OF THE FOLLOWING MEDICATIONS, YOU CAN NOT BE WAXED TODAY:      

-ACCUTANE    -ADAPALENE    -ISOTRETINOIN      -RENOVA    -ALUSTRA     -TAZAROTENE    -TRETINOIN    -AVAGE    -DIFFERIN     -AVITA

YOU MAY EXPERIENCE SKIN SENSITIVITY/THINNING, WHICH CAN RESULT IN SKIN LIFTING FROM THE FOLLOWING: Sunburned skin, Retinol, certain medical conditions, pregnancy, antibiotics, other medications not listed, menstruation.

CORONOA VIRUS LIABILITY RELEASE:  

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. It is believed that an asymptomatic individual can be infected with and transmit COVID-19 without their knowledge.

Due to the global pandemic outbreak of COVID-19 and for the safety and protection of the health of our practitioners and clients we are implementing additional safety measures in compliance with the safety precautions published by the Center for Disease Control, State of Minnesota, and MN Board of Cosmetology.

Symptoms of COVID-19 Include:

Fever or chills
Cough
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
New loss of taste or smell
Sore throat
Congestion or runny nose
Nausea or vomiting
Diarrhea

I agree to the following:

I understand the above symptoms and affirm that I, as well as all household
members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.

I affirm that I, as well as all household members, have not traveled outside of the country or to any city or state considered to be a “hot spot” for COVID-19 infections within the past 30-days.

I understand that Mindful Practice and Lovdahl Salon and Studio LLC and cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

I understand that Mindful Practice and Lovdahl Salon and Studio LLC and are taking extra precautions in order to preserve the health of the practitioners and their clients.

I agree to cancel or reschedule my appointment if I, as well as any household members, are currently exeriencing or have experienced ANY COVID-19 symptoms listed above within the past 14 days.

I agree to cancel or reschedule my appointment if I, as well as any household member, has been diagnosed with COVID-19 within the past 30 days.

I agree to cancel or reschedule my appointment if I, as well as any household member, is currently pending COVID-19 test results.

By signing below, I agree to each statement above and release Mindful Practice, Lovdahl Salon and Studio LLC as well as their practitioners and staff, from any and all liability for exposure or harm due to COVID-19 or any other contagion.

I acknowledge that the information I have given in this consent form is accurate and complete. By signing below, I confirm that I understand and agree to all terms and statements in this form.

Additionally, By signing below, I confirm that I have reviewed, understood, and signed this form on the same day of my scheduled appointment at Mindful Practice.

CONSENT AND SIGNATURE:
No known medical conditions/informed consent. I have read and completed the client intake form in its entirety and in truth. I acknowledge that I have been advised of the potential harmful or negative side effects (such as redness, bumps, soreness, itching) that the facial or body waxing procedure may cause to those who have specific medical or skin conditions. I further state that I have no known medical condition that might be aggravated by the procedure or any medical condition that would prevent me from complying with or heeding to the Professional’s instructions or these warnings. I also agree to defend, indemnify and hold harmless the Professional from any and all claims, actions, expenses, damages, and liabilities, including reasonable attorney’s fees which might be asserted against them as a result of my having this procedure performed, or my purchase of the products sold. As used in this Agreement, the terms “Professional” include all of their respective officers, directors, agents, employees, successors, and assigns.

If any actions is brought to enforce the terms of this Agreement, the prevailing party shall be entitled to its costs and reasonable attorneys’ fees. Any claims arising out of this Agreement will be resolved through blinding arbitration using the rules of the American Arbitration Association.

This Agreement will remain in effect for this procedure, and all future procedures conducted by the Professional or any other Professional conducting business at the establishment listed within this Agreement.

I agree that this Agreement is binding upon me, and my heirs, legal representatives and assigns. I represent that I am over 18 years of age and that I have the right to enter this Agreement.  

 

** IF ANY PROBLEMS OR ISSUES OCCURE POST WAXING, PLEASE CONTACT ANDI IMMEDIATELY 218-461-7792**

First Client's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Email*

Confirm Email*
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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