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2639 Hickory Grove Rd. suite 180 Acworth, GA 30101
Mon-Fri: 10 am-7 pm
Sat: 10am - 5pm
770-529-3088
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Vajacials and Intimate Brightening
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Address
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If yes, please list allergies:
Layout
Do you have or are you prone to:
Ingrown Hairs
Scaring or Keloid
Bumps
Hyperpigmentation
Bruising
Diabetes
Allergies
Have you used any of the following in the last 48 - 72 hours:
Accutane
Retin-A
Alphahydroxy Acid
Glycolic Acid
Resorcinol
Scrub or Peel
Other skin thinning medications?
Have you ever been treated for cancer?
Yes
No
If yes, please list medications:
CONFIDENTIAL HEALTH INFORMATION
Do you use a tanning bed?
Yes
No
If there is any other illness or condition for which you are presently being treated by a amedical professonal?
Use of any of these medications increases the possibility of a reaction. Please inform the technician if you have begun taking any new medications since your last session.
Please note waxing does have certain side effects such as skin removal, redness, scabbing, bruising, scarring, swelling, tenderness, pimples, ingrown hairs, and/or hyperpigmentation. Diabetes increases the risk of poor healing and infection.
Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. The most common occurrence of this is in a Brazilian Bikini Wax.
FEMALE CLIENTS
Because of water retention and for your personal comfort, avoid hair removal two days before and after your menstrual cycle.
PLEASE INITIAL WHERE INDICATED TO SHOW YOU HAVE READ AND UNDERSTAND EACH SECTION
I have read the above information and if I had any concerns, I have addressed them with my wax technician. I give permission to my technician to perform the waxing procedure we have discussed and will hold him/her 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 prescriptions drugs or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions. I have received a copy of, read, and understand the post-treatment care instructions. I am willing to follow the recommendations made by my wax technician for a home care regimen that can minimize or eliminate the possibility of a poor outcome. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment, I will consult my technician immediately. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written statements. I certify that I have read and fully understand the above paragraphs and that I had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the wax technician performing my service responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today
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