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

Are you on or near your menstrual cycle?
YesNo

PLEASE NOTE: Sugaring hair removal will not be done on Bikini or Brazilian, during your menstrual cycle.

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, 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, 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.