Waxing Intake Form

PLEASE BEGIN BY CLICKING HERE TO READ THE POLICIES AND DISCLAIMERS ON THE WEBSITE, THEN RETURN TO COMPLETE THIS FORM.

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Birthdate*

Date

Cell Phone Number (For Text Communications)*

Please enter a valid phone number.

Email (Used only for secondary form of communication)*

example@example.com

Occupation*

Emergency Contact (First & Last Name, Phone #)*

Please list first and last name and phone number

Have you received waxing services in the past?*

YesNo

What areas of the body have you had waxed in the past?*

If you have received waxing services in the past, did you have any negative reactions? Please explain.*

Please list all allergies and sensitivities:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all medications and supplements currently taken, including over-the-counter and street drugs:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. MANY MEDICATIONS AND OVER-THE-COUNTER SUPPLEMENTS AND TOPICAL PRODUCTS CAN CAUSE SIGNIFICANT SKIN LIFTING, TEARING, BRUISING, ETC. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all past and current diagnosed medical conditions, including but not limited to: acne, arthritis, anemia, autoimmune diseases, blood clots, broken bones, cancer, cardiac conditions, communicable disease (acute or ongoing), diabetes, fainting, headaches/migraines, hormonal issues, nerve conditions, serious injuries, skin conditions, sleep apnea, surgeries, etc. Please list as much detail as possible, including dates and whether the condition is controlled or ongoing.*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. MANY MEDICATIONS AND OVER-THE-COUNTER SUPPLEMENTS AND TOPICAL PRODUCTS CAN CAUSE SIGNIFICANT SKIN LIFTING, TEARING, BRUISING, ETC. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

List any areas where you have known bruises, abrasions, cuts, cysts or blemishes, or other areas to avoid:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. MANY MEDICATIONS AND OVER-THE-COUNTER SUPPLEMENTS AND TOPICAL PRODUCTS CAN CAUSE SIGNIFICANT SKIN LIFTING, TEARING, BRUISING, ETC. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Please list all topical products currently used on the area to be waxed, including brand names and how often they are used:*

DISCLAIMER: Failure to provide full and complete information may result in adverse reactions to the treatment at no fault of the therapist. MANY MEDICATIONS AND OVER-THE-COUNTER SUPPLEMENTS AND TOPICAL PRODUCTS CAN CAUSE SIGNIFICANT SKIN LIFTING, TEARING, BRUISING, ETC. Please review all contraindications and inform the therapist prior to your appointment. All information is kept private and confidential and is used only to help the therapist determine the safest course of treatment.

Are you pregnant?*

YesNo

By checking the box below, I understand that I am agreeing to following the recommended after-care routine as discussed with the Esthetician. If I do not follow the recommended after-care and the Esthetician feels that it is a contraindication, I understand that my future service(s) may be canceled, and I will not hold the Esthetician liable for any adverse reactions during or after the service:*

I Agree

By checking this box, I understand that there is a 48 HOUR cancelation/appointment change policy, with a late fee of up to 100% of the originally scheduled service price. (See full Cancelation Policy on the website.)*

Yes, I understand that I may have to pay up to 100% of the originally scheduled service price if I cancel or change my appointment with less than 48 hours notice.

By checking this box, I understand and agree that any illegal activity or requests for illegal activity will result in immediate dismissal and will be reported to the authorities.*

I understand and agree.

By submitting my electronic signature below, I agree that all information provided is complete and honest. I have read and agree to all policies, disclosures and disclaimers provided via www.lotusorganicsdayspa.com.

Signature* Date*

Are you sure you have read and agreed to all separate policies and disclaimers published on the website?*

Yes, I have read and agree to all policies and disclaimers published on the website.