AUTHORIZATION AND CONSENT FOR WAXING Please enable JavaScript in your browser to complete this form.1Information2Questionnaire3AgreementPlease read and complete this form carefully. To the client You have the right to be informed about the procedure(s) to be administered, including benefits, risks, and potential side-effects, so that you can decide whether to proceed. You are encouraged to ask TIPS N TOES LTD. any questions you may have and to consult with a healthcare provider if you have additional questions. Procedure Waxing is a procedure to remove unwanted hair from its roots. Hot wax is applied to the skin and then quickly pulled away, taking hairs with it. Side Effects Waxing may cause side effects. The side effects listed here are merely examples and are not intended to be an exhaustive list. Every person is different, and there is no guarantee that you will not experience more severe side effects. The most common side effects include quickly dissipating, mild discomfort when the wax removes hair from its root. Waxing may cause inflammation, welts, hives, skin lifting, and reddening or small breakouts. This is usually not severe and typically will subside within a few days. Please contact us immediately if you experience more severe or long-lasting side effects. Waiver I understand and acknowledge that there are risks involved with the waxing procedure(s), including, but not limited to, those side effects listed above. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby waive TIPS N TOES LTD.’s liability if such results or complications occur. I further understand that my failure to follow post-procedure instructions may also lead to undesired results, complications or effects and hereby waive TIPS N TOES LTD.’s liability if such results or complications occur. In consideration for TIPS N TOES LTD. performing this procedure(s), I agree that I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure(s) or side effects I may experience after the procedure(s) is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against TIPS N TOES LTD., its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of the procedure(s). I understandQuestionnaire: By signing this authorization form, you declare that the answers given herein are true and complete to the best of your knowledge. False or misleading answers can lead to complications and/or undesirable results. Please indicate your answer by selecting per question and provide detail where appropriate. Have you taken Accutane within the past 12 months? *YesNoIf so, provide date of last dose: *Are you pregnant, diabetic, or receiving cancer treatment? *YesNoHave you recently received any exfoliating treatments or chemical peels? *YesNoAre you using acne medications (prescribed or over the counter) including: Retin-A, Differin, Tazorac, Atralin, or other retinoids? *YesNoIf so, please specify and provide date of last dose: *Are you taking antibiotics, birth control, or hormone replacements? *YesNoIf so, please specify and provide date of last dose: *Do you have AIDS, Lupus, or other chronic condition(s) that may compromise the skin barrier? *YesNoIf so, please specify: *Do you have any allergies including allergies to wax or latex? *YesNoHave you used a tanning bed or experienced prolonged sun exposure within the past 24 hours? *YesNoDo you have rosacea, eczema, psoriasis, cracked or open skin, severe varicose veins, or any skin sensitivities? *YesNoIf so, please specify: *Are you menstruating or about to begin menstruating? *YesNoPreviousNextClient Signature *Clear SignatureClient Name *FirstLastBirth DateLayoutPhoneEmail *I am over 18 years old. *YesNoGuardian Signature *Clear SignatureGuardian Name *FirstLastDate *Procedure Waxing is a procedure to remove unwanted hair from its roots. Hot wax is applied to the skin and then quickly pulled away, taking hairs with it. Side Effects Waxing may cause side effects. The side effects listed here are merely examples and are not intended to be an exhaustive list. Every person is different, and there is no guarantee that you will not experience more severe side effects. The most common side effects include quickly dissipating, mild discomfort when the wax removes hair from its root. Waxing may cause inflammation, welts, hives, skin lifting, and reddening or small breakouts. This is usually not severe and typically will subside within a few days. Please contact us immediately if you experience more severe or long-lasting side effects. Waiver understand and acknowledge that there are risks involved with the waxing procedure(s), including, but not limited to, those side effects listed above. I understand that any false or misleading information I have given may lead to undesired results and complications and hereby waive TIPS N TOES LTD.’s liability if such results or complications occur. I further understand that my failure to follow post-procedure instructions may also lead to undesired results, complications or effects and hereby waive TIPS N TOES LTD.’s liability if such results or complications occur. In consideration for TIPS N TOES LTD. performing this procedure(s), I agree that I will assume the risk and full responsibility for any and all injuries, losses, or damages, which might occur to me while I am undergoing this procedure(s) or side effects I may experience after the procedure(s) is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against TIPS N TOES LTD., its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of the procedure(s). By submitting this form I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to, and authorize TIPS N TOES LTD. to perform, the procedure(s) described above on me. GDPR Agreement *I consent to having Tips N Toes store my submitted information.Send me a copy.PreviousSubmit
