Eyebrow Consultation and Consent Form

Client Details

Full Name: *

Date of Birth: *

Contact Number: *

Email: *

Medical Information

Are you currently taking any medication? *

Please list: *

Do you have any allergies? *

Please list: *

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? *

Please specify: *

Have you used Retin-a, Renova or Accutane (an oral form of Retin-a) in the past 6 months? *

Please specify and include dates if possible: *

Are you using any other skin thinning products and/or drugs? *

Please specify: *

Have you ever been treated for cancer? *

When and what types of therapies did you receive? *

Are you diabetic? *

Please list any other illness/condition you are currently experiencing, or being treated for by a medical professional:

General Information

Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon? *

Do you use a tanning bed? *

What skin products do you regularly use on your skin? *

Female Clients Only

When is your next menstrual cycle due to begin?

Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.

Consent

Please read the following information carefully.

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.
I have read the above information and if I have any concerns, I will address these with my therapist.

I give permission to my therapist to perform the waxing procedure we have discussed and I will hold them and their staff harmless from any liability that may result from this treatment.
I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically.

I understand my therapist will take every precaution to minimize or eliminate negative reactions as much as possible.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.

I certify that I have read, and fully understand the above statements and that I have had sufficient opportunity for discussion to have any questions answered.

I understand the procedure and accept the risks.

I will not hold the therapist responsible for any of my conditions that were present, but not disclosed, which may be affected by the treatment performed today.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above. *

Tap or click on the signature above to sign

Data Protection and Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.