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FACIAL WAXING, EYEBROW AND EYELASH TINTING AND EYEBROW HENNA CONSULTATION AND MEDICAL WAIVER

Full name: *

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Date of Birth: *

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Please fill in Address: *

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Phone number: * Please enter your phone number.

Email: * Please enter your email.

Occupation: * Please enter your answer here.

How did you find out about us? * Please enter your answer here.

Do you follow us @beautyologygeelong on: *

Facebook

Instagram

Not yet! but I will!

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Here are some simple yes / no questions. Please answer these to the best of your ability. If you have any concerns about the questions below, please do not hesitate to talk to your therapist.

Have you used Alpha Hydroxy Acid (AHA) or Glycolic products in the last 48-72 hours? *

Yes

No

I don't know

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Have you taken a medication containing Isotretinoin (e.g. Roaccutane) or Retin-A during the previous 12 months? *

Yes

No

I don't know

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Are you using any other skin thinning products and/or drugs? *

Yes

No

I don't know

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Do you use a solarium/tanning bed? *

Yes, this week

Yes, but not recently (longer than 1 month)

No

Please select at least one choice above.

Do you have Diabetes, currently on any form of immuno suppressant therapy, or have any other condition that may cause delayed healing? *

Yes

No

Please select at least one choice above.

Do you have, or do you think it is possible you may have a Blood Borne Communicable Disease? Eg: Hepatitis C Virus (HBC), Hepatitis B Virus (HBC), Human Immunodeficiency Virus (HIV) *

Yes

No

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Are you pregnant or have you recently had a baby? *

Yes

No

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Do you have any allergies? (dye, essential oils etc) *

No

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Have you taken antibiotics in the last 3 months? *

Yes

No

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Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements: *

No

Please select at least one choice above.

Do you fill in your brows with makeup? *

No

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What skin products do you regularly use on your skin? * Please enter your answer here.

Please note that waxing, tinting and Henna can have certain side effects such as skin removal, redness, swelling, itching and tenderness.

I have read the above information and if I have any concerns I will address these with my therapist. I give permission to my therapist to perform the waxing/tinting procedure we have discussed and will hold Beautyology and staff harmless from any liability that may result from this treatment. All information I have provided to the questions above is true and correct including all known allergies or prescription drugs or products I am currently ingesting or using topically. I understand that my therapist will take every precaution to minimise or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my therapist for a home care that can minimise or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult my therapist immediately.

Social: I grant Beautyology the irrevocable right to photograph me, video record me and record my image, voice, likeness and opinions and to use my picture, name, voice, photograph, silhouette, and other reproductions of my physical likeness and sound in any manner you elect (hereinafter "photographs"), and I also grant you the irrevocable right and license to utilise the results and proceeds of my services and the photographs therein, without payment or compensation, in the unlimited, unrestricted distribution, advertising and promotion for any and all uses.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosure. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understant the procedure and accept the risks. I do not hold the therapist whos signature appears below responsible for any of my conditions that were present or not disclosed at the time of this procedure which may be affected by the treatment performed today.

I agree to the above. * Please check it here.

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Signature Date *

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