First Name *

Last Name *

Email *

Phone *

How did you hear about us?

Have you used any AHA or glycolic products in the past 48-72 hours? *

Yes
No

Are you currently using Retin-a, Renova or Accutane? *

Yes
No

Are you using any other skin thinning products or drugs? *

Yes
No

Are you diabetic? *

Yes
No

Do you bruise easily? *

Yes
No

Please list all medications you are currently taking?

Have you ever been waxed before? *

Yes
No

Do you have sensitive skin? *

Yes
No

Do you frequently develop ingrown hairs after shaving/waxing? *

Yes
No

Anything else you think we should know? *

Yes
No

If yes, please provide additional details.

Waxing does have certain side effects that occur differently on every individual. These side effects can include, but are not limited to, redness, swelling, tenderness, minor bruising, etc. I have read the above information and will address all concerns with my esthetician. I give full consent to my esthetician to perform the waxing procedure(s) we discussed. I have filled in the above questions with honesty to the best of my ability. In the event that I may have additional questions or concerns regarding my treatment, I will consult my esthetician immediately. I agree that this constitutes my full disclosure and supersedes any previous verbal or written disclosures. 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 the skin care procedure. *

Today's Date *

Waxing

Thanks for submitting your form, we have received it! We look forward to you seeing you at your appointment.

Thanks for submitting your form, we have received it! We look forward to you seeing you at your appointment.

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Derma Plane Form