CONSENT FORM

Please fill out and submit prior to your appointment

Have you shaved within 10 days of your appointment date?

Yes

Please list any allergies:

Please list any medications or supplements:

I have not used a scrub, Retin-A, Retinol OTC, take home micro-dermabrasion, glycolic peels, other peels, exfoliated or tanned in the last 72 hours.

Yes

Are you taking Accutane (or similar) or have you in the past year? * Brand names include: Accutane, Claravis, Sotret, Accutane, Amnesteem, Myorisan

Yes

* Accutane Warning: * Using retinoids (accutane or similar) can cause skin to lift during the sugaring or waxing process, resulting in serious injury and possible scarring. For your own safety, we cannot sugar or wax you until you have been off of Accutane or similar medications for over a year's time.

By typing my name below, I acknowledge that I have read and agree to receive the treatments or series of treatments listed above.

I understand that with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks.

I agree to adhere to all safety post care including: no peels, tanning or wet room services; no swimming/spas/hot tubs for 48 hours after waxing; and all home skin care protocols as recommended by my service provider.

I am over 18 years of age or I have parental consent co-signed below.

I will call to inform my service provider of any complications or concerns I may have as soon as they occur.

Please enter full name as signature and date

Thank You for submitting!