Electronic Waxing Waiver - WaiverElectronic

Welcome to WAXON® Summerhill

For the safety of all our Clients we ask that you fill out this form.

Please fill in your name: *

Please enter your full name.

Are you 18 years or older? *

Yes

Please select at least one choice above.

Date of birth: *

Please enter valid date.

For Waxing: Clients under the age of 16 MUST be accompanied by a legal guardian when attending their first waxing appointment at WAXON. Please provide full name of parent / legal guardian. We will not perform waxing services on anyone under the age of 10, even with parental consent.

For Laser: Clients under the age of 18 MUST be accompanied by a legal guardian when attending their first laser appointment at WAXON. Please provide full name of parent / legal guardian.We will not perform laser services on anyone under the age of 16, even with parental consent.

Name of parent / legal guardian: Please enter your name.

Parent or legal guardian: Are there any services that are not approved? Please enter your answer here.

Signature of parent / legal guardian:

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Gender: * Please select one here.

Phone number: * Please enter your phone number.

Email: * Please enter your email.

Postal Code: * Please enter your answer here.

How would you like to be reminded of your appointments? *

Text Message

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How did you hear about us? *

Friend / Family

Media / News

Social Media

Website / Google

Walking by

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If you answered Friend / Family, please provide their name. (If you refer 3 friends you get $50 on your account!) Please enter your answer here.

Are you currently pregnant, trying to conceive, or nursing?

Yes

Not Applicable

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Have you had laser hair removal in the past? *

Yes

Please select at least one choice above.

If YES, which area of the body / face Please enter your answer here.

Which other method(s) of hair removal have you used within the last 6 weeks? Select all that apply.

Shaving

Waxing

Electrolysis

Tweezing

Threading

Depilatory Creams

Please select at least one choice above.

Please select the option that best describes your skin when exposed to sun: *

Always burn, never tan

Always burn, sometimes tan

Sometimes burn, always tan

Moderately pigmented, tan well

Deeply pigmented, never burn

Please select at least one choice above.

Are you currently under the care of a physician or dermatologist? If yes, for what reason: Please enter your answer here.

Do you have / or had history of the following? Select all that apply.

Herpes I or II

Keloid scarring or hypertrophic scar formation

Light induced seizures

Radiation Therapy

Please select at least one choice above.

Are you currently taking any medications? This includes non prescription, vitamins, and natural supplements.

Yes

Please select at least one choice above.

If YES, please list all medications Please enter your answer here.

Are you currently taking antibiotics? *

Yes

Please select at least one choice above.

In the last 6 months have you used any of the following types of medications? Select all that apply.

Anticoagulants

Blood-thinning

Photosensitizing

Anti-inflammatory

Please select at least one choice above.

Have you had radiation therapy in the area being treated? *

Yes

Please select at least one choice above.

If YES, which area of the body? Please enter your answer here.

Have you taken Accutane in the last 6 months? *

Yes

Please select at least one choice above.

Have you used any of the following products in the last 4 weeks? Select all that apply *

Glycolic acid

Salicylic acid

Retin A

Anti-aging products

Acne products

Skin lightening products

None of the above

Please select at least one choice above.

Have you had dermabrasion or a chemical peel in the last 4 weeks? *

Yes

Please select at least one choice above.

Do you have any tattoos or permanent make up? *

Yes

Please select at least one choice above.

If YES, which area of the body / face? Please enter your answer here.

Have you had any cosmetic injections, including botox or fillers, in the past 2 weeks? *

Yes

Please select at least one choice above.

Have you been in the sun or tanning booth, or used self tanning lotions within the last 4-6 weeks? *

Yes

Please select at least one choice above.

If you have any allergies, please list here: Please enter your answer here.

*Please inform us should any of the above information change.

The use of certain medications and tanning can hinder the result of your services including extreme redness, scarring, and lifted skin. Please consult your Waxologist/Laserologist if you have ANY questions or concerns about your service(s).

I authorize the Estheticians at WAXON Waxbar (“Waxologists/Laserologist”) to perform services(s) on me today and in the future. I understand that during or after waxing and laser hair removal services, I may experience irritation or adverse reactions including, without limitation, redness or scarring of the skin, which may be caused or worsened by pre-existing medical conditions and/or medical treatments I am undergoing. I agree to notify WAXON Waxbar of any pre-existing or future medical conditions that may arise prior to receiving waxing or laser service(s). I acknowledge and understand that Waxologists are not health care practitioners and cannot, and do not claim to, diagnose or give advice on any medical condition(s) of the skin or otherwise. I agree to seek immediate medical attention and advice from a qualified medical practitioner should any irritation or adverse reaction occur as a result of service(s). I hereby release, remise and forever discharge WAXON Waxbar and its owners, employees, successors and assigns, of and from any and all claims, liabilities, demands, actions and causes of actions relating to any loss, damage or injury that may be sustained by me or property belonging to me, whether caused by negligence or otherwise, while receiving service(s) or while on the WAXON Waxbar premises. The release shall bind my heirs, executors, administrators, agents, successors and assigns and shall apply to any service(s) I receive at WAXON Waxbar today and in the future.

LASER HAIR REMOVAL DISCLAIMER

All personnel in the treatment room, including me, must wear protective eyewear to prevent eye damage from this light energy.  The treated area may be red and swollen for two to twenty-four (2–24) hours or longer. Cooling the area after the treatment (for example, ice packs, topical gels) may help reduce discomfort and swelling.  Common side effects include temporary redness (erythema) or mild "sunburn"-like effect that may last a few hours to 3-4 days or longer. Other potential side effects include, but are not limited to, crusting, irritation, peeling, bruising, redness, ingrown hairs, itching, pain, burns, scabbing, swelling (edema), broken capillaries, bronzing, and acne or herpetic breakouts. There also is a risk of unsatisfactory appearance and failure to achieve the desired result.  Pigment changes, including hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting one to six (1-6) months or longer or permanently may occur. Freckles may temporarily or permanently lighten or disappear in treated areas.  Lightening or darkening of vascular lesions may occur.  Serious complications are rare but possible, such as scarring, blood clots, skin loss, hematomas (collection of blood under the skin), and allergic reaction to medications or materials used during the procedure.  There is a chance of additional side effects like blanching and significant redness.  There is no guarantee that the expected or anticipated results will be achieved.  Sun, tanning bed, or tanning lamp exposure, the use of self-tanning creams, and not adhering to the post-treatment instructions provided to me may increase my chance of complications. I must avoid the sun, tanning beds, and sunless tanning lotions and use sunblock (SPF 45 recommended) after treatment. There is a possibility of coincidental hair removal when treating pigmented or vascular lesions in hair-bearing areas. There is a risk that the hair regrowth may be changed, such as little or no regrowth or more regrowth than before.  There is a high risk of paradoxical hair growth in people of Middle Eastern and Mediterranean descent and those who have an ill-defined hairline with no obvious transition of the hairline to the face.  I should call my provider as soon as possible if I have any concerns about side effects or complications after treatment.  Not providing my medical history before proceeding with a light-based treatment could impact treatment results and cause complications.

By signing below, I certify that I have read and fully understand the above paragraphs and that I have had sufficient opportunity for discussion and to have any questions answered in connection there with. *

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Electronic waxing waiver-a practical software

For Waxing: Clients under the age of 16 MUST be accompanied by a legal guardian when attending their first waxing appointment at WAXON. Please provide full name of parent / legal guardian. We will not perform waxing services on anyone under the age of 10, even with parental consent.

For Laser: Clients under the age of 18 MUST be accompanied by a legal guardian when attending their first laser appointment at WAXON. Please provide full name of parent / legal guardian.We will not perform laser services on anyone under the age of 16, even with parental consent.