Your Full Name
    REQUIRED

    Your Email (will not be shared)
    REQUIRED

    Your Phone Number
    REQUIRED

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

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

    Have you used the tanning bed in the past 24 hours
    YesNo

    Are you diabetic?
    YesNo

    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?
    YesNo

    Please list, if answered yes

    Are you on or near your menstrual cycle?
    YesNo

    Do you have any allergies?
    YesNo

    Please list, if answered yes

    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 and/or Jackie Hinckley, 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 and/or Jackie Hinckley, 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.

    Please sign here
    REQUIRED

    Date
    REQUIRED: Select a date from the drop down