Client Consent Form
WAXING AND TWEEZING
Type of Service
CONSENT AND RELEASE AGREEMENT FOR
WAXING AND TWEEZING
We recommend that no client, under any circumstances, receive a waxing or tweezing service if any form of the following scenarios applies:
• Pre- or post-exposure to the sun, within 24 hours of receiving the service.
• Use of Renova, AHA, Differin, Retin A, acid-based products, or any other retinoid or retinol related products.
• Under a doctor’s care for any skin-related condition or illness.
• History of: reactions to tweezing or waxing, allergies (please inform us of all).
• Diabetes, flat moles, phlebitis, and fragile capillaries-any of these can cause increased sensitivity to waxing and tweezing.
• Increased sensitivity may occur during pre-menstruation or while taking antibiotics.
• Skin conditions such as broken skin, inflammation, active herpes or suspicious growths.
• Use of Accutane or any products related to Accutane.
We recommend that you refrain from any of the following after receiving waxing or tweezing services:
• Sun exposure at least 24 hours after waxing or tweezing.
• Saunas, steam rooms, and other heat sources.
• Application of Retin A, Renova, AHA products at least 48 hours after waxing and tweezing.
• Abrasive products on any areas waxed or tweezed.
• For Bikini waxing, no exercise, intercourse or tanning for at least a day.
We would like to inform you of the following:
Individual sensitivities may occur during tweezing and/or waxing services, regardless of a client’s history of sensitivity.
Please inform your technician if you have experienced any of the following: sensitivities to scented cosmetic formulations, tea tree oil, or any other form of topical treatment.
PLEASE NOTIFY YOUR TECHNICIAN BELOW OF ANY QUESTIONS OR CONCERNS REGARDING YOUR PROCEDURE OR IF ANY OF THE ABOVE SCENARIOS APPLY TO YOU OR ANY MEDICAL CONDITIONS.
Client medical History
Please let the technician know if any of the following apply to you:
Active Skin Disorders: Cold Sores, Shingles, Impetigo, Psoriasis, Pink Eye, Sun Burn, Severe Acne, New Scar Tissue
Blood Disorders: Sickle Cell, Hemophilia
Accutane (must be 0_ for 6 months)
Steroids (must be 0_ for 6 months)
Retinol/Retin-A (stop using 7 days prior)
Do the medical list above apply to you in any way?**
If yes, name your condition.
Allergic reaction to any medications such as Lidocaine, Tetracaine, Epinephrine, Dermacaine, Benzyl alcohol, Carbopol, Lecithin, Propylene glycol, Vitamin E Acetate, ect.**
Allergies to metals, food, latex, antibiotics.**
Do you have menstral period?**
If yes, when?
Currently on any blood-thinning prescription drugs.**
If yes, when?
Special requests, concerns or remarks for technician:
I grant permission to TN-Beauty, Thunyatorn LLC, Thai Serenity Spa to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, and Pinterest. If no photo please inform your your artist.**
STATEMENT OF CONSENT AND RECITALS:
PLEASE READ AND CHECK ALL LINES
I acknowledge I am age 18 or older.
I understand that after my service, there will be no refunds. No exceptions.
I acknowledge it is not reasonably possible for my technician to determine whether I might have an ALLERGIC reaction to the coconut oil, healing oil, aloe vera, baby powder, or any waxing products used in this process. I agree to forego a patch test and accept the risk that such reaction is possible and I already informed technician all the allergics and medical conditions I have.
The staff at TN-Beauty, Thai Serenity Spa and Thunyatorn, do not practice medicine, does not accept health insurance, and have made no representation to the contrary.
The information provided on this form is accurate and complete to the best of my knowledge, and that TN-Beauty, Thai Serenity Spa and Thunyatorn are not responsible for complications or problems arising from any incorrect or omitted information. I will contact my doctor immediately, if I experience abnormal pain, discomfort, infection due to lack of proper after-care or health related issue.
Some individuals will have complications related to waxing procedures. These complications are usually mild and last only a few days. However, extreme complications are always a possibility. I accept these risks and agree to hold Thunyatorn and its employees and contractors harmless for same.
I have read all the Precare guidelines and acknowledge that Aftercare instructions are available on www.TN-Beauty.com. I agree to follow them to the best of my ability. I agree that any follow up work needed, due to my negligence will be done at my own expense.
I certify that I have read or have had read to me the contents of this whole form. I understand the risks and alternatives involved in this procedure(s) and I have had the opportunity to ask questions and all of my questions have been answered.
By signing below, I acknowledge, understand and agree with all the items on this form.**
Consent to Treat a Minor:
By my signature below, I hereby authorize technician to administer services to my child or dependents.
**Please fill out all required fields
Please let us know if you would you like to receive a copy of this statement and consent.