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Online Store!
Epionce
Obagi Skin Care
Grow Beautiful Lashes With Latisse!
Sign up for VIP Program!
Services
Lash Extensions & Lash Lift
Facials & Waxing
New TREATMENT Launch
Laser Services
Massage Therapy
Body Treatments
Spa Packages
bareMineral Make Up Tutorials
A Little Something Extra
Obagi Prescription products!
Promotions and Events
MOD VIP Program! Join and save!
Payment Plans
TruSculpt 3D
Secret RF
New Patient Forms
Skin Care History
Massage Form
Eyelash Extension Consent Form
TruSculpt 3D Form
Body Sugaring/Wax Hair Removal
Laser Consultation Request
Laser Hair Removal Health History Form
Lash Lift Consent
Career Opportunities
Reviews
Contact Us
Sign In
My Account
About Us
Online Store!
Epionce
Obagi Skin Care
Grow Beautiful Lashes With Latisse!
Sign up for VIP Program!
Services
Lash Extensions & Lash Lift
Facials & Waxing
New TREATMENT Launch
Laser Services
Massage Therapy
Body Treatments
Spa Packages
bareMineral Make Up Tutorials
A Little Something Extra
Obagi Prescription products!
Promotions and Events
MOD VIP Program! Join and save!
Payment Plans
TruSculpt 3D
Secret RF
New Patient Forms
Skin Care History
Massage Form
Eyelash Extension Consent Form
TruSculpt 3D Form
Body Sugaring/Wax Hair Removal
Laser Consultation Request
Laser Hair Removal Health History Form
Lash Lift Consent
Career Opportunities
Reviews
Contact Us
New Patient Forms
Skin Care History
Massage Form
Eyelash Extension Consent Form
TruSculpt 3D Form
Body Sugaring/Wax Hair Removal
Laser Consultation Request
Laser Hair Removal Health History Form
Lash Lift Consent
MOD Skin & body clinic
Body Sugaring & Wax Hair Removal Consent
Date
MM
DD
YYYY
Name
*
First Name
Last Name
Birthday
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
How did you find us?
*
Have you used any Alpha Hydroxy Acid (AHA) or Glycolic products in the past 48-72 hours?
*
Yes
No
Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)?
*
Yes
No
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?
*
Do you suffer from any medical problems EX: Diabetes, high blood pressure?
*
What method of hair removal do you currently use?
*
Do you have any adverse reaction to any skin care products?
*
Do you have an allergy to latex?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you currently on your menstrual cycle?
*
Yes
No
Are you currently taking medications?
*
If so, please list all (including over the counter drugs/herbal supplements
By clicking "Agree and Consent to Treatment" I give permission to my therapist to perform the sugaring/waxing procedure we have discussed. I hear by release MOD Skin and Body and specific estheticians from liability associated with the procedure. 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.
*
Agree and Consent to Treatment
Thank you!
