C O N S E N T F O R M Name * First Name Last Name Email * Date of birth (MM/DD/YYYY) * Phone * (###) ### #### Please list any questions or concerns that you have with your skin and/or the reason for your visit: * Which service(s) are you booking? * In the past year, have you had any type of surgery? Including cosmetic procedures. * Have you used or currently using the following: Retinol, Retin-A, Accutane, Differin, or any other exfoliating product? I understand, have read, and have fully completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. While all treatments are recommended to achieve the best possible results, I do understand that not all treatments will have the same results on every client; therefore no guarantee can be given. I also understand that withholding information or providing misinformation may result in contraindications and / or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the technician of any of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release Teresa Nicole Wax and Body from liability and assume full responsibility thereof. Consent is valid for one year. If any changes do occur please make sure and inform your Esthetician. * I accept I decline * First Name Last Name Date * MM DD YYYY Thank you!
