MA Admin

Waxing & Hair Removal Release Form

Are you using Retin-A (trentoin) or any of the following: Adapalene, Isotretinoin, Clindaymycin/Tretinoin, Tazarotene, Acitretin, Bexarotene, Alitretinoin, Fluocinoleone/Hydroquinone/Tretinoin? If yes, your technician will not remove hair from that area and 3” surrounding area; this information is on your prescription facts. Yes No

Are you taking Accutane? (If yes, your technician will not be able to perform any hair removal). Yes No

Are you currently undergoing any: Chemical Peels, Dermabrasion, Facial Surgery, Laser Treatment? (If yes, you need to have a doctors release that there has been enough time since treatment in order to service the area affected). Yes No

Are you using any over the counter products (for wrinkles or blemishes) that contain: Glycolic acids, Alpha Hydroxy Acids, Benzoic Acids, Benzoyl Peroxide, Salicylic Acids? Yes No

Waxing & Hair Removal Release Form

Are you under a physician’s or dermatologists care? Yes No

Are you taking any medications that can cause thinning of skin such as: blood thinners and corticosteroids? (If yes, your technician will do patch test to determine whether or not you can have the service and/or consult your prescribing physician). Yes No

Are you taking any medication that may cause water retention? (Some hormone drugs containing estrogen, blood pressure lowering medications, antidepressants, and steroids may cause water retention). Yes No

Are you currently pregnant? Yes No

Wax & Hair Removal Release Form

Waxing & Hair Removal Release Form

Waxing & Hair Removal Release Form

Authorization