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BRAZILIAN WAX STUDIO
FACIAL CONSENT FORM
First name
Last name
Do you have any allergies? If so, list below
Are you currently using or have used any of the following medications or topicals in the past?
Accutane
Differin
Tazorac
Retinol/Retin-A/Retinoids
Glycolic/Salicylic
Antibiotics
none
Are you currently pregnant?
*
Yes
No
Have you had sun exposure in the last 24 hours?
*
Yes
No
Do you have any health concerns that I should be aware of?
*
Yes
No
Do you have metal implants?
*
Yes
No
Have you had any laser, microdermabrasion, chemical peel treatments, Botox or injectables within the last 30 days?
*
Yes
No
Do you have any of the following? Select all that apply.
Eczema
Dermatitis
Open lesion, cold sore, Herpes
HIV or Hepatitis
Lupus, or any autoimmune disease
Active acne or infection
Hyperthyroidism, Lymphedema or any lymphatic drainage issue
Epilepsy or any neurological disorder
Diabetes
Do you wear contact lenses?
*
Yes
No
Do you smoke or vape?
*
Yes
No
Rate your level of stress from 1 to 4. (1=lowest, 4=highest)
*
1
2
3
4
I have read and agree to LOVE THY WAXER LLC
Policies, Terms and Conditions
Your Signature
Clear
Select a date
Submit
Thanks for submitting!
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