Medical Consent Bellas By Paola | Consentimiento Médico Bellas By Paola

Client Medical Form

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First And Last Name *

First

Last

Age *

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?* *

Have you used Retin-A, Renova, or Accutane within the past year? If so, when? If so, when?* *

Answer *

Are you using any other skin thinning products and/or drugs that thin the blood?* *

Do you use tanning beds and/or are exposed to the sun on a regular basis? *

Are you currently taking any medications? If so, please list. *

Have you been treated for cancer? If yes, when and what types of therapies were used? *

Please list any illness/conditions which you are currently being treated for by a medical professional. *

Do you have any open skin lesions on the face?* *

Do you have any allergies? If so, please list. *

Please note that waxing can have certain side effects such as skin removal, redness, swelling, tenderness, etc.

I have read the above information and have given an accurate account of the questions and if I have any concerns, I will address these concerns with BellasbyPaola.
I give permission to BellasbyPaola to perform the waxing procedure we have discussed and will hold her harmless from any liability that may result from this treatment.
I agree to adhere to all safety post care including: no peels, tanning, or wet room services; no swimming/spas/hot tubs for 72 hours after waxing.
understand that BellasbyPaola will take every precaution to minimize or eliminate negative reactions as much as possible.

Signature *

Clear Signature

708226831