Name *
Name
Phone *
Phone
Date of birth *
Date of birth
Have you shaved within 2 week of your appointment date? *
Are you currently using or have you used any of the following in the past 7 days?
Check all that apply
Do you have tendencides towards any of the following?
Check all that apply
Are you taking Accutane (or similar) or have you in the past year? *
Brand names include: Accutane, Claravis, Sotret, Accutane, Amnesteem, Myorisan
Accutane Warning: *
Using retinoids (accutane or similar) can cause skin to rip off during the waxing process. For your own safety, we cannot wax you until you have been off of Accutane or similar medications for over a year's time
I have completed this form to the best of my ability. I will consult with Chelsey Cueva regarding any medicine I am currently taking and any skin tendencies that may be problematic. I give permission to Chelsey Cueva to perform the waxing procedure and will hold her 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 Chelsey Cueva will take every precaution to minimize or eliminate negative reactions as much as possible. I am willing to follow recommendations made by Chelsey Cueva for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult with the Chelsey Cueva immediately. 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 liability waiver and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.
Date *
Date