Please Fill Out the Following "Green Form" Prior To Your Appointment

(This form is for our info only and does NOT book your appointment)

My Little Wax Bar
Wax/Facial Client Consultation
Personal and Confidential

I have read and answered the above information/questions and if I have any concerns, I will address these with my esthetician/My Little Wax Bar.

 

I give permission to my esthetician/My Little Wax Bar to perform waxing/skin care services as discussed and will hold her and her staff harmless from any liability that may result from this treatment/service.

 

I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically.

 

I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

 

I have read and understand the post-treatment home care instructions/suggestions posted on this establishments website.

 

I am willing to follow recommendations made by my esthetician for a home care regimen that can/may minimize or eliminate possible negative reactions.

 

In the event that I may have additional questions or concerns regarding my treatment/service or suggested home products/post-treatment care, I will consult the esthetician immediately.

 

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/will have sufficient opportunity for discussion to have any questions answered.

 

I understand the procedure/service and accept the risks.

 

I will not hold the esthetician or My Little Wax Bar responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure/service, which may be affected by the treatment/service performed on the day of my service(s). 

 

By submitting this form I confirm that the above information is current and correct and I will notify my Esthetician/My Little Wax Bar if any of the above information changes prior to any future treatments that I may have at this establishment.