CONSENT & WAIVER FOR ALL WAXING & TWEEZING Client Name: PhoneAddress: Email Esthetician Name; Date of Consultation MM slash DD slash YYYY MEDICAL INFORMATION:*Do any of the following pertain to you?Currently taking medication(s) prescribed by a Dermatologist especially for acne or wrinkle prevention Yes No Accuta ne/ Differ in/Tazorac/Glycolic Acid/ Retin A/ Renova or ary prescribed medication for acne or anti-aging Yes No Clarasonic Brush/ Facial Exfoliating Scrubs/ Facial Peels Obagi Yes No Currently or recently ill Yes No Antibiotics/ Antiviral/ Aspirin/ Ibuprofen medications Yes No Autoimmune Disease/ Diabetes/ HIV/ Hepatitis/ Lupus Yes No Allergies/ Allergic reactions Yes No Birth Control/ Hormones Yes No Botox/ Juvederm/ Restylene) other filler injections Yes No Bruise Easily/ Unhealed Cuts Yes No Herpes/ Cold Sores/ Fever Blisters Yes No Irregular Pigmented Moles/ Warts/ Growths Yes No Keloids/ Pigmented Scars Yes No Pregnant/ Breast Feeding Yes No Previous Laser Procedures/ Chemical Peels/ Dermabrasion/ Microdermabrasion Yes No Recent Surgery/ Medical Procedures Yes No Recent Travel Yes No Smoke Yes No Sunburn/ Tanning/ Indoor Tanning Yes No Under the care of a physician that would affect or interfere with the followings service(s) Yes No PLEASE ACKNOWLEDGE THE FOLLOWING & DISCUSS WITH YOUR ESTHETICIAN: Tweezing and waxing may cause sensitivities, even in clients with no prior history of any known sensitivities We are not able to provide service if you have broken skin, inflammation, suspicious growths, active herpes, using any AHA or BHA/ acid-based type products, or have a history of prior reactions to waxing. If you are prone to Herpes/ Cold Sores/ Fever Blisters, you may need a prescription for Acyclovir/ Zovirax from your physician prior to havinq treatment. Always avoid exfoliating treatments during a breakout. You may be more sensitive to the procedure if you are pre-menstrual or pregnant. Anytime the skin is broken, there is a slight risk of bacterial and/ or viral infection. You must keep treated area clean and dry. Moisturize and protect the newly exposed/ exfoliated skin with adequate sunscreen/ SPF 1 5 or higher, as you are more susceptible to sunburn and skin damaqe Avoid the use of any AHA or BHA/ acid-based type products for 2-4 days following service. It is recommended that following the waxinq procedure, you: Avoid sun exposure for at least 24-48 hours after service Avoid Jacuzzi, saunas, steam rooms, or other heat sources Avoid using any kind of exfoilating, AHA or BHA/acid-based type products Consult with the Esthetician if you are using such products and discuss the appropriate length of time for discontinued use of products after service. *By signing below, I acknowledge that I have read and understand the foregoing informed consent and agree to the service with associated risks. I hereby agree to have tweezing and/ or waxing services performed and agree to follow all of the pre and post treatment instructions. I release and hold Lash & Brow Envy, its employees and its representatives harmless from z and all claims/ damages associated with this procedure.Client Signature: Date MM slash DD slash YYYY Parent/ Guardian: Date MM slash DD slash YYYY (If client is under 18 years of age)
