Utopiatanning.com

Waxing Consent Form
Name:______________________________________________________________Date of Birth:_____________________________________________
Address:_____________________________________________________________City:_______________________Zip:_________________________
Telephone:__________________________________________________________Email:___________________________________________________
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.
Are you taking or have you ever taken Accutane?. YES or NO
If you have, but are no longer taking Accutane, how long has it been?_____________________________________________________________________ Are you using or have you used Retin-A, or Renova?. …. YES or NO
If you have, but are no longer using Retin-A, how long has it been?______________________________________________________________________ Are you taking any type of antibiotics, birth control, hormone replacement or blood thinners?. …. YES or NO
Do you have any health problems your therapist may need to know about?. YES or NO
If so, what are they?____________________________________________________________________________________________________________ Please read and initial the following information about contraindications.
Anyone showing signs of redness, rashing, 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 cannot receive waxing services. Anyone currently using or having used in the past five days the following medications: Retin-A, Renova, Differinor Avita cannot receive waxing services. I confirm that the above-mentioned contraindications for my servicestoday do not apply to me.
Initials: __________
Anyone having just received a microdermabrasion treatment or an acid peel cannot have a waxing service tothe same area.
Initials: __________
Regarding Herpes Simplex Types I and II Anyone with a history of Herpes Simplex I or II has been advised thatwaxing service may cause an outbreak to re-surface.
Initials: __________
I certify that all the information above is correct and hereby give my consent for a waxing treatment. I also understandthat it is my responsibility to inform Utopia Tanning & Skin Care Spa of any changes pertaining to any information I have given on this form.
Initials: __________
I have read the above contraindications and the related Pre and Post instructions pertaining to the professional servicesI am about to receive and do therefore agree to waive all liabilities toward Utopia Tanning & Skin Care Spa, andpracticing licensed skin care professionals, for injury or damages.
Client signature:________________________________________________________________________ Date:________________________________

Source: http://utopiatanning.com/wp-content/uploads/2011/07/Waxing-Consent-Contraindication-Form.pdf