Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
In the past 2 weeks have you had a rash located or near genitals, hands, feet, chest, or mouth?
Yes, but has gone away
Yes, has gotten worse
No
Do you currently have one or more contraindication for this service:
Please Select
Pregnancy
Varicose Veins
Open Wounds
Bypass Surgery
Pace Makers
Muscle Relaxers
Blood Thinners
Decreased Skin Integrity
Temperature Sensivity
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. I also release the rights to any photos taken on Wild+Free premises, giving Wild+Free, LLC permission to use photos for marketing purposes.
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