MOD Skin & body clinic

Body Sugaring & Wax Hair Removal Consent

Date

YYYY

Name

First Name

Last Name

Birthday

YYYY

Phone

(###)

###

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How did you find us?

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

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?

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

Do you suffer from any medical problems EX: Diabetes, high blood pressure?

What method of hair removal do you currently use?

Do you have any adverse reaction to any skin care products?

Do you have an allergy to latex?

Are you pregnant?

Are you currently on your menstrual cycle?

Are you currently taking medications?

If so, please list all (including over the counter drugs/herbal supplements

By clicking "Agree and Consent to Treatment" I give permission to my therapist to perform the sugaring/waxing procedure we have discussed. I hear by release MOD Skin and Body and specific estheticians from liability associated with the procedure. 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 esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

Agree and Consent to Treatment