Sugar Crave - Sugaring Waiver

First Name *

Last Name *

Email Address *

Phone Number *

Are you using Retin-a, Renova or Accutane (oral form of Retin-a)? *

Yes

No

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

Yes

No

Have you used the tanning bed in the past 24 hours? *

Yes

No

Are you diabetic? *

Yes

No

Do you have any medical conditions, including but not limited to: skin disease, hepatitis, HIV/AIDS, herpes, seizure disorder, active infections, heart condition, diabetes, rash, lymph edema, high/low blood pressure? *

Yes

No

If yes, please describe below:

Are you on or near your menstrual cycle? *

Yes

No

This question does not apply to me

Do you have any allergies? *

Yes

No

If yes, please describe below:

Please Note: Hair removal services cannot be done on anyone who is on Accutane, Antibiotics, or Retin-A, severe reaction could occur. For women, on or near their menstrual cycle your skin may be more sensitive and could hurt more then usual during Sugaring services. For hygiene purposes, please plan to wear a tampon, diva cup or disc during your appointment. Sugaring will not be done if you have gone to a tanning bed within the past 24 hours.

I have read the above information and if I have any concerns, I will address to my sugar technician. I give permission to my sugar technician, Jennifer McLean, Jackie Hinckley and/or Jessica Colborn, to perform the sugaring procedure we have discussed and will hold her harmless from any liability that may result from this treatment. I have given an accurate account of the questions asked above, including all known diseases, allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my sugar technician will take every precaution to minimize or eliminate negative reactions as much as possible.

I agree that this constitutes full disclosure, and that supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any question answered. I understand the procedure and accept the risks. I do not hold the sugar technician, Jennifer McLean, Jackie Hinckley and/or Jessica Colborn, whose signature is below, responsible for any of my conditions that were present, but not disclosed at the time of this sugaring procedure, which may be affected by the treatment performed today.

Full Name *

Date *

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