SKINRAY WAX AND BEAUTY PATIENT CONSENT FORM & HEALTH QUESTIONNAIRE
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Have you used any Alpha hydroxy acids (AHAs), Beta hydroxy acids (BHAs), Glycolic or retinol products in the area to be treated in the last 48-72 hours?
Are you currently using or have used Retin-A, Renova or Accutane within the past year? If so when?
Do you use tanning beds/and or exposed to the sun on a regular basis?
Planning to be
MEDICAL HISTORY QUESTIONS Please list ALL allergies and medications:
Please list any illness/conditions in which you are currently being treated for by a medical professional:
Have you been treated for cancer? If yes, when and what therapies were used:
Are you taking any blood thinners?
I agree that I have read and understand this consent form, and that I understand the information contained in it. I am obligated to inform my esthetician/therapist if any of my conditions change in the future. Please note that waxing can have certain side effects such as: skin lifting, redness, swelling, tenderness, etc. If I have any concerns, I will address these with my Esthetician. I give permission to my Esthetician to perform the waxing procedure we have discussed and will hold the Esthetician harmless from any liability that may result from this treatment. 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. I understand that my Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.
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