Brow and Lash Specialist - Jessica Devereux

Waxing Consent Form

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours?  No  Yes
Are you using Retin-a, Renova or Accutane?  No  Yes
Are you using any other skin thinning products and/or related medication?  No  Yes
Are you exposed to the sun daily or are you planning to spend more time in the sun soon?  No  Yes
Do you use a tanning bed?  No  Yes
Are you diabetic?  No  Yes
Are you allergic to Latex?  No  Yes
Are you currently taking medications? If so, please list (including antibiotics/OTC/supplements):
_________________________________________________________________________________________
What skin products do you regularly use on your skin?
_________________________________________________________________________________________
Have you ever been treated for cancer? If yes, when and what types of therapies were used?
_________________________________________________________________________________________
Please list any other illness/condition you are currently being treated for by a medical professional
_________________________________________________________________________________________
(Female clients) When is your next period due to begin? ________________________ (Always wait five days
after your period starts. Because of increased water retention and sensitivity, you should avoid hair removal
two days before your cycle is due and two days after it is completed.)

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc. and anyone
showing signs of any skin irritation or similar problems cannot receive waxing services. Anyone having just received a
microdermabrasion treatment or an acid peel cannot receive waxing services to the same area. Anyone with a history of
HSV I or II should be aware that waxing services may cause an outbreak.

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission
to my therapist to perform the waxing procedure we have discussed and will hold the therapist harmless from any liability
that may result from this treatment. I understand my therapist will take every precaution to minimize or eliminate any
negative reactions. I have read and understand the post-treatment home care instructions. In the event that I may have
additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult
the therapist immediately. I understand the procedure and accept the risks.

I release “Brow and Lash Specialist - Jessica Devereux” of any and all liability and wish to proceed with services by
the Technician.

Client Signature: _____________________________________ Date: ______________________

Client Name (Print): __________________________________ Phone: _____________________

E-mail: ________________________________________________________________________

Parent (if Client is under 18 years of age): ____________________________ Date: ____________

©Jasmine Christensen