APPENDIX A

CUSTOMER MEDICAL HISTORY

Customer Information
Name:__________________________________________________________________________________
Address: _____________________________________________________________________________________
City: __________________________________________ State:_____________________________________
Home Phone: ___________________________________ Work Phone:________________________________
Email address:_________________________________________________________________________________

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? ◯ Yes ◯ No

Are you currently using Retin-a, Renova, or Accutane (an oral form of Retin-a)? ◯ Yes ◯ No

Are you currently using any other skin thinning products and/or drugs? ◯ Yes ◯ No

Do you presently have any open skin lesions or any active herpes outbreak(s) (cold sore or genital)? ◯ Yes ◯ No

Are you exposed to the sun on a daily basis or are you planning to sunbathe or spend substantially more time in the sun following today’s treatment/procedure? ◯ Yes ◯ No

Do you use a tanning bed? ◯ Yes ◯ No

Do you have diabetes, phlebitis or any skin irritations? ◯ Yes ◯ No

Are you currently taking any medications? If so, please list all (including over the counter drugs/herbal supplements):

What skin products do you regularly use on your skin?

Have you ever been treated for cancer? If yes, when and what types of therapies were used? Please list any other conditions or illnesses you are currently being treated for by a medical professional:

***When is your next menstrual cycle due to begin?

***Due to water retention and for your own personal comfort, you should avoid hair removal at least two (2) days before your menstrual cycle is due and at least two (2) days after it is completed.

CUSTOMER ACKNOWLEDGMENT REGARDING REQUESTED SERVICES

I UNDERSTAND AND ACCEPT that waxing has certain side effects such as skin removal, redness, swelling, tenderness, discomfort, and other side effects. I have read and completed this form in its entirety and I will consult Esthetician if I have any concerns. I give Esthetician permission to perform the waxing procedure we have discussed and hold him/her/them, his/her/their staff, and Minido LLC harmless from any liability that may result from this treatment/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 Esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

I have read and understand the post-treatment home care instructions on the Dowasti® website/app. I am willing to follow recommendations made by Esthetician for a home care regimen designed to minimize or eliminate possible negative reactions. If I have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Esthetician only during my treatment or procedure. If I have any further questions or concerns in the hours or days following my treatment, I will contact Dowasti®’s customer service directly at info@dowasti.com or (347) 705-4842. If I experience any persistent, negative, or painful skin reactions following my treatment or procedure, I will immediately call 911 or contact my medical provider.

I agree that this constitutes full disclosure, and that it 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 questions answered. I understand the procedure and accept the risks. I do not hold Esthetician or Minido LLC responsible for any of my conditions that were present, but not disclosed at the time of this skin care treatment/procedure, which may be affected by the treatment performed today.

Client Name (print): ____________________________________________________________________________
Client Name (signature): _________________________________________ Date: _______________________
Esthetician: ___________________________________________________ Date: _______________________