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							                                  WAXING CONSENT
Name: _______________________       Date: ___________      DOB: ______________
Email:_________________________ Permission to email for promotions: Yes No
Address: ___________________________________________________________
City: ________________________ State: ___________ Zip Code: ____________
Home Phone: _____________________ Cell: ______________________
Referred By: ________________________________________
Emergency Contact: ______________________ Contact Phone: __________________

Please answer the following questions. All information given today is fully confidential and is
only used so that your therapist can provide the safest and most comfortable treatment possible.

Please place a check next to any of the following you have used:
Accutane (in the last year):
Alpha Hydroxy Acid (AHA) (in the last 72 hours):
Glycolic products: (last 72 hours)
Retina-A (72 hours):
Revona (72 hours):
Tretinoin (72 hours):

Do you use a tanning bed? No Yes
Do you have diabetes? No Yes
Have you had a microdermabrasion or peel in the last week? No Yes
Have you had a physician administered peel in the last 2 years? No Yes
Have you had laser resurfacing in the last 1 year? No Yes
Have you had laser hair removal in the last 3 months? No Yes

Are you taking any type of antibiotic, birth control, hormone replacement or blood
thinners, including alcohol or aspirin?
If so, which: ________________________________________________________

Do you have any health issues your Aesthetician may need to know about?
If so, what are they?
_______________________________________________________________________

Please list any additional illness/condition you are currently being treated for by a
medical professional
________________________________________________________________________
________________________________________________________________________

Have you ever had any adverse reactions to waxing? _______
If yes, please explain: _____________________________________________________

For female Brazilian waxing only:
When do you expect the start of your next menstrual cycle? ________
Anyone showing signs of redness, rashes, open and or abraded skin, an active lesion of Herpes
Simplex I or II, sunburn (either from natural sun exposure or a tanning bed), psoriasis or eczema,
recent scar tissue, cannot receive waxing services.

Those using Retin-A, Renova, Differin, Tretinoin or Avita cannot receive waxing services.

Regarding Herpes Simplex Types I and II; anyone with a history of Herpes Simplex I or II, has
been advised that waxing service may cause an outbreak to re-surface.

Please note that waxing does have certain side effects such as skin removal, redness, swelling,
tenderness, etc. Caution is also recommended in regard to flat and raised moles, phlebitis and
fragile capillaries.

Always allow five days for menstrual cycle. Because of water retention and for your own
personal comfort, you should avoid hair removal two days before your cycle is
due and two days after it is completed.

The ideal hair growth for Bikini & Brazilian waxing is ½ inch. Hair shorter than this may not be
removed effectively, as the wax needs to attach to the hair shaft. Hair longer than 1 inch will need
to be trimmed during the service which will lengthen the service and increase the cost of the
service. We have the right to refuse services for all waxing if proper hygiene has not been
followed. Please cleanse before Brazilian and Bikini waxes. A waxing is contraindicated if an
STD is present for safety reasons.

It is important to care for the waxed area properly after treatment to avoid ingrown hairs,
breakouts or other reactions. I understand that after the waxing procedure, I should practice the
proper home care, and I have received a copy of this.

I have read the above information and if I have any concerns, I will address these with my skin therapist. I
give permission to my therapist to perform the waxing procedure we have discussed and will hold her, her
staff, and Natural Way Wellness Spa LLC harmless from any liability that may result from this treatment. I
have given an accurate account of the questions asked above including all known allergies or prescription
drugs or products I am currently ingesting or using topically. In the event that I may have additional
questions or concerns regarding my treatment or suggested home product / post-treatment care, I will
consult the esthetician 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 esthetician, whose signature appears below, 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 Name (printed) _______________________

Client Name (signature) _______________________                          Date __________________


Esthetician __________________________________                           Date ___________________