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Waxing_consent

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									            Waxing, Brazilian & Bikini Waxing Consent [Year]
I _________________________________________ give consent to Victorias Cosmetic

Medical Clinic Qualified Beauty Therapist to perform the following wax services.

                    Facial                Body                   Intimate



      I have not used a scrub, Retin-A, take home micro-dermabrasion, glycolic peels,
       other peels, exfoliated or tanned in the last 72 hours ________(initial)
      I have been off Roaccutane for at least 12 months ______ (initial)
      I am /not taking any blood thinning medication ______(initial)
      I am aware that some possible side effects include redness, swelling, pimples which
       are temporary and generally fade within 72 hours ______(initial)
      Waxing of soft tissue may cause the skin to tear. The most common occurrence of
       this is in a Brazilian bikini wax. ____(initial)
      For Brazillian waxing only -- I am aware that it must not be during my menstrual
       cycle ____(initial)
      I do not have any open lesions, active herpes outbreak (facial , body or genital)
       _____(initial)
      I understand that with treatment certain risks are involved and that any
       complications or side effects from known or unknown causes could occur. I freely
       assume these risks. ___(initial)
      I agree to adhere to all safety post care including: no peels, tanning, or wet room
       services for 72 hours.
      I will adhere to all home skin care protocols as recommended by Victorias Cosmetic
       Medical Clinic. _____(initial)
      I am over 18 years of age or I have parental consent co-signed below. ____(initial)
      I will call to inform Victorias Cosmetic Medical Clinic of any complications or
       concerns I may have as soon as they occur. ____(initial)

My signature acknowledges that I have read and agree to receive the following treatments
or series of treatments listed above and that I adhere to all the above statements I have
initialled.

Client Signature:___________________________ Date:_________________

Witness or Parent Signature: _________________Date: ________________

N.B. We have the right to refuse services for all waxing if proper hygiene has not been
followed. Please cleanse before Brazilian and Bikini waxes. Thankyou.

Victorias Cosmetic Medical Clinic
12.4.2012

                                                                                          Page 1
            Waxing, Brazilian & Bikini Waxing Consent [Year]




Victorias Cosmetic Medical Clinic
12.4.2012

                                                        Page 2

								
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