Name
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First Name
Last Name
Date
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MM
DD
YYYY
Date of Birth
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MM
DD
YYYY
Email
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Address
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Phone
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(###)
###
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Emergency Contact
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First Name
Last Name
Emergency Contact Phone
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(###)
###
####
How did you hear about us?
Google search
Word of mouth
Social Media
Website
MEDICAL HISTORY
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Do you have or have you had any of the following conditions? If yes, please select them:
Have you ever been treated for cancer?
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If yes, when and what types of therapies were used?
Any known allergies?
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If yes, what type of allergies?
List any medications you take regularly, including vitamins, herbal supplements, aspirin:
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Any other illness/condition:
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Are you pregnant?
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SKIN HISTORY
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Do you have any tendencies to:
Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 72 hours?
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Are you using Retin-a, Renova or Accutane?
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Are you using any other skin thinning products and/or drugs?
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Do you use a tanning bed?
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Have you ever had a waxing treatment before?
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Have you ever had a reaction to waxing?
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What skin products do you regularly use on your skin?
I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in the above information. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.
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I hereby consent to and authorise Danielle KYD to perform the following procedure:
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I agree to the following:
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1. I am aware of side effects including, but not limited to: allergic reaction, irritation,
redness, burning, swelling, soreness, bruises or bumps.
2. I am aware certain medications and over the counter products can increase the risk of injury when combined with skin care services. I am not using any medications that may cause such injury/reaction. I will advise my esthetician if this changes.
3. I have been off of Accutane for at least 12 months and I am not using Retin-A, any products contacting alpha hydroxyl, or doing any other skin thinning treatments.
4. I have not used a scrub, take home micro-dermabrasion, glycolic peels, other peels, exfoliated or tanned in the last 72 hours.
5. I do not have any open skin lesions or active herpes outbreak (cold sore or genital).
6. I agree to adhere to all safety post care including: no peels, tanning or wet room services; no swimming/spas/hot tubs for 72 hours after waxing; and all home skin care protocols as recommended by my service provider.
7. For Brazilian and/or bikini waxing, I will notify my service provider if I am on my
menstrual cycle.
8. I understand that my esthetician have the right to refuse services for all waxing if proper hygiene is not followed.
9. I am over 18 years of age or I have parental consent co-signed below.
By selecting yes, I acknowledge that I have read and agree to receive the treatments or series of treatments
listed above and that I will adhere to all of the aforementioned statements that I have initialed. I fully understand the risks and side effects associated with the treatment. I freely assume these risks and
release the provider and the Esthetician of all liability.
