Saloon Form

Customer Information

Customer First Name*

Customer Last Name*

Customer Email*

Customer Phone Number*

Gender*
MaleFemale

Age*

Customer Address

Street Address Line 1

Street Address Line 2

City*

State*

Postal/Zip Code*

Health and Skin Checker

Please answer the health and skin checker for the safety of the procedure:
Have you done any waxing before?Are you currently taking any medications?Have you had any skin thinning treatments before?Are you Pregnant? (Female)Do you have sensitive skin?Do you have skin allergies?Do you bruise easily?Are you prone to scarring and hyperpigmentation?

Substance

Are you currently using any cosmetic products that may contain the following substance? Kindly check if yes and if no, leave it blank.
Accutane Retin-A or retinoidsRenovaDifferinAHABHAGlycolic Acid

Waiver Consent

I am providing my consent to complete the procedure I am requesting for I am duly aware of the side effects of waxing to my skin during or after the procedure such as:
skin redness, swelling, skin irritation, bruises, or bumps.
I acknowledge and completed health and skin checker, efficiency, and accuracy.
I was instructed and enlightened that some cosmetic additives or chemical substances itemized were hazardous when coupled with waxing and may most likely cause disappointing results and side effects to my skin area.
I hereby affirm that I have read and fully understand the above, am over eighteen years of age and am legally liable for my own decisions/actions.
By signing below, it means that I agreed to the terms indicated in this document.

Customer Signature*

Date Signed*