General Intake & Waxing Consent – Celebrity Skin Studio

Todays Date*

First and Last Name*

First Last

If you go by another name or nickname please let us know

Current Age*

Date of Birth*

Email*

Best email to notify you of appointment information as well VIP news and info.

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you allergic or sensitive to anything? If so please list.

Do You Use Sunscreen Daily?*

Have you ever had any issues with waxing?*

Such as skin lifting, burns, sensitivity, rashes, irritation or breaking out?

yes
no

If you answered yes, please describe what happened and indicate when this occurred.

Are you currently using any of the following products?*

If you checked any of the items above please list those specific products you are using below.

Are you being treated for any medical conditions?*

If yes please list, if no please indicate no.

Do you take any medications?*

Don't forget to list any topical medications, hormonal medications or birth control.

Have you recently had any injections such as Botox Fillers, or any other facial treatments or surgeries?

If yes please list procedure and date.

If this is your first visit to Celebrity Skin Studio

How did you hear about us? Is there anyone we should thank for your referral?

24 Hour Cancellation Policy*

Celebrity Skin Studio has a strict 24 hour Cancellation Policy. In the event of a late cancellation/no show
the fee is 50 percent of the total cost of services booked. Cancellation Fee will be charged to card on file. In the event there is an issue with card on file, the client will be billed via email.

I agree to the Cancellation policy

Are you a Minor or under legal guardianship?*

If yes, this form must be signed in the below section for parent's or legal guardians.

yes
no

Consent For Treatment & Liability Waiver*

I understand that if I have any concerns, I will address these with my technician/esthetician. I give permission to my technician/esthetician to perform treatments/procedures and will hold him/her/them and his/her/their staff harmless and nameless from any liability that may result from this treatment/procedure. I understand I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read and fully understand the above paragraphs and that I have been provided sufficient opportunity for discussion and to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician/esthetician, responsible for any of my conditions that were present but not disclosed at the time of this procedure that may be affected by the treatment performed today I agree to update my service provider of any changes to this form. I understand photos may be taken for documentation purposes and may be used in promotional materials and social media posts.

By checking the box and signature below, I agree to Consent for Treatment and Liability Waiver

Signature*

Date*

This final section applies to Parental/Legal Guardian Consent only

This section must be filled out if client is a minor or a ward under legal guardianship. Please fill out all fields.

For Parent or Legal Guardian, please list any necessary instructions.

Parent/Legal Guardians Printed Name

First Last

Phone

Please list a phone number you can be reached at if the service provider needs to contact you.

Parent or Legal Guardians Signature

By my digital signature I I give permission for her/him to receive services at Celebrity Skin Studio LLC. I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s or ward's behalf for any disclosures or liability described on those forms. I agree to supervise any service bookings and home care procedures that are recommended as a result of the treatment.

Date