Name

First Name

Last Name

Daytime Phone Number

How did you hear about Jane?

I,_____(A)______ am the legal parent/guardian of ____(B)____ and I consent to the treatment of this minor who’s date of birth is___(C)___.

Please write your/guardian's name here

Please write the full name of the monitory you are the guardian of here.

please write the birthdate of the minor here.

Emergency Contact Number

Section

Do you have or are you prone to;

Ingrown hairs

Hypertrophic scarring

Hyperpigmentation

Bruising

Acne

Warts

Allergies

None of the above

If YES to 'allergies'.please list allergies here:

Section 1

Section 2

When was the last time you used a tanning bed?

Have you used any skin thinning medications?

Please list them out here or answer NO

Have you received Botox treatment recently or do you plan on receiving Botox within 14 days of your treatment here?

YES

Have you had any serious operations, chronic illness, chronic virus infections or parasitic infections?

YES

Are you a transplant recipient, pregnant, or do you have electronic implants?

YES

New use of any of the medications listed above increases the possibility of a reaction. Please inform the aesthetician if you have begun taking any new medications since your last session. Please note waxing does have side effects such as skin removal, redness, scabbing, bruising, scarring, swelling, ingrown hairs, tenderness, hyperpigmentation or blemishes. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. The most common occurance of this is in a Brazilian bikini wax.

Client (your) initials and agreement the information above is true

Type your initials here

Today's date is

Type today's date here

Aesthetician Initials:

Aesthetician Date:

Your form has been submitted.
Thank you!

GENERAL CONSENT FORM

please ensure this consent is completed prior to your first appointment time.

jane off main