CONSENT FORM Please enable JavaScript in your browser to complete this form.Single Line TextDate of BirthMobile Phone #Email AddressHow were you referred to Teresa Nicole Wax and Body?Please list any questions or concerns that you have with your skin and/or the reason for your visit:Which skincare and cosmetic products are you presently using? (Facial Clients Only)Have you been under the care of a physician, dermatologist, or other medical professional within the past year?YesNoIf yes, please explain:In the past year, have you had any type of surgery—including cosmetic procedures?YesNoIf yes, please explain:Have you had, or are you presently experiencing, any of these conditions? Select any/all that apply:Hormone ImbalanceVaricose VeinsScar EasilyEpilepsyEczemaHigh/Low Blood PressureDiabetesHepatitisPoor circulationHIV/AIDSAny Active InfectionsFever blisters / cold soresSkin diseases / skin lesionsDo you use or have you ever used any of the following in the past year? Select any / all that apply:Adapalene Hydroxl AcidAccutaneDeferinGlycolic AcidRetin-ASalicylic AcidAHARenovaAny Vitamin A-derived product (Accutane)If you indicated use of any of the above, please provide further explanation: Have you ever experienced an allergic reaction to any of the following? Select any / all that apply:CosmeticsSunscreenFragranceMedicineIodineShellfishFoodAHAsLatexIf you indicated a reaction to any of the above, please provide further explanation:If you’ve experienced an allergic reaction to a substance not listed above, please indicate substance and reaction here: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 AcceptI DeclineName *FirstLastEmailSubmit
