Swan Lake Brazilian Wax — Waxing Consent Form

Last Name

First Name

M.I.

Gender

Female Male

DOB (mm dd yyyy)

Email Address

Street Address

City

State

Zip

Mobile Phone

How did you hear about Swan Lake Brazilian Wax?

CONFIDENTIAL HEALTH INFORMATION

Do you have or are you prone to
Do you have or are you prone to:	Yes	No
Ingrown hairs?
Scarring or Keloid?
Bumps?
Hyperpigmentation?
Bruising?
Diabetes?
Allergies?
If yes, please list allergies:

Have you used any of the following in the last 48-72 hours
Used in last 48–72 hours?	Yes	No
Accutane?
Retin-A?
Alpha hydroxy Acid?
Glycolic Acid?
Resorcinol?
Scrub or Peel?
Other skin thinning medications? If yes list medications:

Have you ever been treated for cancer?

Yes No

Do you use a tanning bed?

Yes No

Are there any other illnesses or conditions for which you are presently being treated by a medical professional?

FEMALE CLIENTS: Because of water retention and for your personal comfort, avoid hair removal two days before and after your menstrual cycle.
- 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.

Important: Use of any of the listed medications increases the possibility of a reaction. Please inform the technician if you have begun taking any new medications since your last session. Waxing can have side effects including skin removal, redness, scabbing, bruising, scarring, swelling, tenderness, pimples, ingrown hairs and/or hyperpigmentation. Diabetes increases the risk of poor healing and infection.

PLEASE INITIAL WHERE INDICATED TO SHOW THAT YOU HAVE READ AND UNDERSTAND EACH SECTION

I have read the above information and if I had any concerns, I have addressed them with my wax technician. I give permission to my technician to perform the waxing procedure we have discussed and will hold him/her harmless from any lability that may result from this treatment. I have given an accurate account of the questions asked above including all known allergles of prescription drugs or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions.

Initial

I have received a copy of, read, and understand the post-treatment care instructions. I am willing to follow the recommendations made by my wax technician for a home care regimen that can minimize or eliminate the possibility of a poor outcome. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment, I will consult my technician immediately.

Initial

I agree that this constitutes full disclosure, and that it supersedes and previous verbal or written statements. I certify that I have read and fully understand the above paragraphs and that I had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the wax technician performing my 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.

Initial

Client Signature

Date

Client Name Printed

Date

Parent Signature (If client is under 18)

Date