WAXING INTAKE & LIABILITY WAIVER

WAXING INTAKE & LIABILITY WAIVER
Full Name

First NameLast Name
Phone
Format: (000) 000-0000.
Email
example@example.com
Date

MonthDayYear
Date
How did you hear about us? (Check one)
FriendInstagramFacebookOther
Have you ever had a reaction to a waxing service?

YesNoIf yes, please describeOther
Do you have vericose veins on your legs?

YesNo
Do you use Glycolic Acid, Salicylic Acid, Lactic Acid or any acid based products on your face or body?

YesNo
Have you had recent microdermabrasion, laser resurfacing or injectable fillers?

YesNo
Treatment Areas

Lip/ChinBrowsFull FaceHalf ArmFull ArmHalf LegFull LegBackChestNeckBikiniBrazilianOther
Are you taking acne medication or vitamin A products?

YesNo
Have you or will you be in the sun or tanning bed within 24 hours of this treatment?

YesNo
By signing below, I understand that topical creams, medical conditions and certain medications can affect the results of waxing.

I understand that I can not be waxed if I have certain contraindications and I hereby release the technician and the company, in which I am voluntary seeking services from, from harm and waive on behalf of myself, my heirs and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damages or loss to myself and/or property that may be caused by any act, or misinformation both intentional or accidentally on this form as well as failure to follow post-care instructions after my service.
Signature
Date

MonthDayYear
Date
I, as parent/legal guardian of the above named patient, a minor, hereby consent and authorize treatment and have no further questions regarding this procedure.
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Parent/Legal Guardian Signature
Date

MonthDayYear
Date
Should be Empty: