Wax Consent Form Name * First Name Last Name Age * Birthday * MM DD YYYY Address * Email * Phone * (###) ### #### Do any of the following apply to you? Diabetes Epilepsy Oedema Phlebitis Hypersensitive skin Varicose veins Psoriasis Poor circulation Sunburns Moles Skin disease Pregnancy Prescribed medicine New scar medicine New scar tissue Others Please specify Do you use any of these products? Retin A Glycolic acid Accutane Oedema Have you had waxing before? * Yes No Do you have any known allergies? * Yes No If yes, please indicate By signing below you have agreed to the following, * I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed and understand the contradictions to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. Thank you!
