Waxing Release Waxing is the procedure of removing unwanted hair by means of employing hot wax to the skin. Fields marked with an * are required. Are you currently under a doctor’s care?* Yes No For what? Are you currently taking cortisone, blood thinners, or diabetic medications?* Yes No Are you currently taking any over-the-counter medications such as Aspirin, Tylenol, Advil, etc?* Yes No Please list any over-the-counter medications you are taking: Are you currently taking Accutane or any other acne medications?* Yes No Since when? Do any of the products in your skin regime contain the following ingredients?*(Check all that apply) Retin-A Renova Differin Salicylic Acid Glycolic Acid AHA Hydroquinone None of the above Have you ever had any of the following?*(Check all that apply) Laser Treatment Chemical Peel Microdermabrasion None of the above Please specify the date(s):Have you ever had an adverse reaction after using a skin regimen?* Yes No Do you use tanning beds?* Yes No Within the last 48 hours?* Yes No Do you have a history of fever blisters or cold sores?* Yes No Name* First Last Email* Signature*I understand that some minor breakout may occur post waxing. I further understand that I must not be using any type of acid exfoliant in the area to be waxed such as chemical peels or Alpha Hydroxy Acid products for at least two weeks prior to the wax service. I must not be using any type of Retin-A medications for at least one month prior to any waxing service. I must be off Accutane for at least one year prior to any waxing service. I understand that I must stay out of the sunlight for at least 24 hours before and after the waxing treatment and wear sun protection with an SPF of at least 20. I understand the procedure of waxing as it has been explained to me above and verbally by the student. I have had the opportunity to ask any questions regarding the procedure. I do not hold the school nor its employees or students liable for any type of reaction that may occur. I understand that if I begin using any of the above products and do not inform my aesthetician prior to hair removal, I am accepting full responsibility for any skin reactions that may occur.NameThis field is for validation purposes and should be left unchanged. 52
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