Healthcare Facial Waxing Consent Form

Healthcare Facial Waxing Consent Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance (if applicable)

Procedure Details

Procedure to be performed (check applicable areas):

Eyebrows    Upper lip    Chin

Sideburns    Forehead    Nose    Ears

Medical History

Are you pregnant or breastfeeding? Yes    No

Patch test performed today: Yes    No

Risks, Benefits, and Alternatives

I understand that facial waxing is a cosmetic procedure involving application and removal of wax to remove hair. Expected benefits include removal of unwanted hair and temporary smoothing of the treated area. I understand and accept that results cannot be guaranteed.

I have been informed of common and uncommon risks which include, but are not limited to: transient redness, swelling, tenderness, bruising, folliculitis, burns, blisters, scarring, pigmentary changes (hypo- or hyperpigmentation), broken capillaries, allergic reaction to wax or aftercare products, and infection. Use of certain medications or topical agents (including retinoids, isotretinoin, or recent chemical peels) increases risk of adverse outcomes.

Alternatives to waxing have been explained, including shaving, depilatory creams, electrolysis, and laser hair removal where applicable. I acknowledge I may decline or withdraw consent at any time prior to or during the procedure.

I agree to follow pre- and post-procedure care instructions provided by the clinic. Failure to follow these instructions may increase the likelihood of complications.

Acknowledgments and Consent

By checking the boxes below I acknowledge that I have read, understand, and agree with the following statements:

I have read and understood the information above, had the opportunity to ask questions, and those questions were answered to my satisfaction.

I have disclosed my medical history, medications, allergies, and any skin treatments I have received within the last 6 months.

I understand the risks described and consent to proceed with the facial waxing procedure(s) indicated above.

I consent to clinical photographs for the purpose of treatment documentation. I understand photographs will be used only in the patient's chart unless I sign a separate release for educational or promotional use.

To the extent permitted by law, I release the clinic and its staff from liability for complications resulting from undisclosed medical conditions, failure to follow instructions, or normal risks of the procedure. This release does not waive claims arising from gross negligence or willful misconduct.

HIPAA / Privacy Acknowledgment

I acknowledge that I have received or been offered the clinic's privacy practices regarding my protected health information. I consent to the use and disclosure of my health information for treatment, payment, and healthcare operations as necessary for the provision of facial waxing services.

I acknowledge receipt of the privacy notice and consent to the use of my information as described above.

Pre- and Post-Procedure Care (Select items apply)

Pre-procedure (do not do within 72 hours unless otherwise directed): Exfoliate    Topical retinoids    Oral isotretinoin (within past 6 months)

Post-procedure care (follow these to reduce complications): avoid sun exposure for 48 hours; avoid facial scrubs and abrasive products for 72 hours; apply cool compresses and recommended products as instructed. If signs of infection or severe reaction occur, contact the clinic immediately.

Patient Certification

I certify that I am the patient or I am authorized to sign on behalf of the patient. I certify that the information I have provided on this form is accurate and complete to the best of my knowledge. By signing below I give voluntary consent for the indicated facial waxing procedure(s) and agree to the terms set forth above.

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