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Spa Waxing Consent Form
Waxing Consent Form
Please fill out form prior to your appointment.
First Name
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Last Name
*
Telephone
*
E-mail
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All information is fully confidential and is used so that your therapist can provide the safest and most comfortable treatment possible.
Have you received waxing services before?
Yes
No
If so, how long ago?
Are you taking or have you taken Accutane?
Yes
No
If so, but are no longer taking Accutane, how long has it been?
Are you using or have you used Retin-A, Renova or Differin Gel>
Yes
No
If so, but are no longer using any of the above, how long has it been?
Are you taking any of the following?
Antibiotic
Birth Control
Hormone Replacement
Blood Thinners
Have you used any of the following in the last 72 hours?
AHA (Alpha Hydroxy Acid)
BHA (Beta Hydroxy Acid)
Glycolic Acid
Retinol
Facial Scrub
Do you have any health concerns your technician may need to know about?
Yes
No
If so, what are they?
Please read and initial the following information about contraindications
Anyone showing signs of redness, rash, open and or abraded skin, an active lesion of Herpes Simplex I or II, sunburn (either natural sun exposure or from UV tanning rays), psoriasis or eczema cannot receive waxing services. Anyone currently using or have used the following medication int he past five days cannot receive waxing services: Retin-A, Renova, Differin or Avita
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Anyone having just received a microdermabrasion treatment or an acid peel cannot have a waxing service to the same area
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Anyone with a history of Herpes Simplex I & II has been advised that waxing service may cause an outbreak to re-surface.
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I certify that all the above information is correct and I hereby give my consent for a waxing treatment. I also understand that it is my responsibility to inform The Spa at the Herrington of any changes pertaining to any information given on this form.
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I have read the above contraindications and related pre and post instructions pertaining to the professional services I am about to receive and therefore agree to waive all liabilities towards The Spa at the Herrington and practicing licensed estheticians for injury or damages.
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First Name
*
Last Name
*
Today's Date
*
Date of Service
*
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