SUGARING CONSENT FORM Name * First Name Last Name Phone * (###) ### #### Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? * Yes No Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? * Yes No Are you using any other skin thinning products and/or drugs? * Yes No Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon? * Yes No Do you use a tanning bed? * Yes No Are you currently sunburned? * Yes No Are you Pregnant? * Yes No Are you diabetic? * Yes No Currently have or had any of the following medical conditions that could compromise your skin and/or services being offered? * AIDS/HIV HEPATITS VARICOSE VEINS ECZEMA/PSORIASIS HERPES CANCER COLD SORES/BLISTERS NONE OF THE ABOVE Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements): * What skin products do you regularly use on your skin? * Have you ever been treated for cancer? If yes, when and what types of therapies were used? * Please list any other illness/condition you are currently being treated for by a medical professional * Please review the following * I have read the above information and if I have any concerns, I will address these with my choosen esthetician. I give permission to my esthtetician to perform the sugaring procedure we have discussed and will hold her and her 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 esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician 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 the esthetician 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 above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. I agree to waive all liabilities toward my esthetician for any injury or damages incurred due to any misrepresentation of my health history. I agree if I begin to use, or are currently using ant products listed in the warning, and failed to inform NUEVAVILLA ESTHETICS LLC prior to current and future treatments, I accept full responsibility for any reactions. I have read and agree to the terms above Thank you!
