Waxing Questionnaire & Consent Form (Page 2 of 2) in pdf

List all illnesses and/or conditions you are presently being treated for by a medical professional.

_____________________________________________________________________________________

Please note waxing does have certain side effects such as skin removal, redness, scabbing, bruising, scarring,

swelling, tenderness, hyperpigmentation, and/or pimples. 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.

Ladies: During menstrual cycle - Because of water retention and for your comfort, avoid hair removal two days

before your cycle starts and two days after.

New use of any of the medications listed on the previous page increases the possibility of a reaction. Please inform

your Technician if you have begun taking any new medications since your last session.

I give permission to my Therapist to perform the waxing procedure we have discussed. I have given an accurate

account of the questions asked above including all known allergies, prescription drugs and/or products I am

currently ingesting or using topically. I understand my Technician will take every precaution to minimize or

eliminate negative reactions.

I have read and understand the post-treatment home care instructions.

I am willing to follow the

recommendations made by my Technician 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 my Technician 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

Technician or Rejuvenation Spa & Laser Services 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.

Client’s Name

____________________________________________ Date ________________

Client’s Name

____________________________________________ Date ________________

Signature

Technician

____________________________________________ Date ________________

Waxing Questionnaire & Consent Form Page 2