Skin Care Release Form

Name

Phone

Date

Email Address

Birthday

Health Related

Are you pregnant or nursing? YesNo

Do you smoke regularly?YesNo

Do you have implants in your body?YesNo

Do you participate in vigorous aerobic activity or sports?YesNo

Do you wear contact lenses? YesNoIf so, please remove contacts prior to facial

Do you wear sunscreen on a regular basis

Have you visited a tanning booth in the past 3 weeks? YesNoIf so, your service may have to be Rescheduled.

Are you currently taking any antibiotics? YesNoNote that use of antibiotic may increase sensitivity.

Skin Care Related

Are you currently using products containing Glycolic?AcidAHSAcid or AHA

How long have you been using the product and how has your skin been reacting to it?

Are you currently using acutance? YesNo

If so, how long?

Have you ever used Hydroquinone (Skin Lightener?) YesNo

If so, how long?

Do you currently Wax, Electrolysis or use Depilatories on your face? YesNo

If so when was your last treatment?

Have you had any of the following?

Microdermabrasion?YesNo

If so when?

Microdermabrasion?

Chemical Peel? YesNo

If so when?

Chemical Peel?

Collagen or Botox?YesNo

If so when?

Collagen or Botox?

I affirm that I have stated all my known medical conditions and answered all my questions honestly. I agree to keep the provider updated as to any changes in my medical profile and understand that there shall be no liability to BEAUTY OF WAX should I fail to do so.

Appointment Rules

I hereby acknowledge and agree to the following: BEAUTY OF WAX requires appointment deposits to secure every appointment made appointment deposits must be submitted at the time of booking or 24 hours before the appointment date.

BEAUTY OF WAX has the right to hold a valid credit card on file in the case that I do not submit a deposit. If I do not call to cancel or reschedule 24 hours before my appointment

I will be charged a 50% cancellation fee for the services scheduled if I have submitted a deposit I will forfeit my deposit.

Client Initials *

By adding your initials you consent to the terms of the form