Waiver for wax procedure, as an online waiver, is your best choice in waiver production.

A'Maries Day Spa Waxing Intake Form

Please fill your name: *

Please enter your full name.

Date of Birth: * (Valid Age Range: 13 - )

Please enter valid date.

Email: * Please enter your email.

Phone number: * Please enter your phone number.

Please fill in Address: *

Please enter address.

How did you hear about us? Please enter your answer here.

Is this your first waxing session? If yes, do you normally shave or Nair? Please enter your answer here.

Has it been more than two weeks since the last time you shaved or used Nair?(You will need at-least two weeks of hair growth in order to have a successful waxing session.)

Yes

No

Please select at least one choice above.

Are you pregnant? *

Yes

No

Please select at least one choice above.

Do you have any allergies? If yes, please list: * Please enter your answer here.

Have you used any Alpha Hydroxy Acid (AHA) or glycolic products in the past 48-72 hours? *

Yes

No

Please select at least one choice above.

Are you using Retin-a, Renova or Accutane (an oral form of Retin-a)? *

Yes

No

Please select at least one choice above.

Are you using any other skin thinning products and/or drugs? *

Yes

No

Please select at least one choice above.

Do you use a tanning bed? *

Yes

No

Please select at least one choice above.

Are you diabetic? *

Yes

No

Please select at least one choice above.

Are you currently taking medications? If so, please list all (including over the counter drugs/herbal supplements): Please enter your answer here.

Have you ever been treated for cancer? If yes, when and what types of therapies were used? Please enter your answer here.

Please list any other illness/condition you are currently being treated for by a medical professional: Please enter your answer here.

(Female clients) When is your next menstrual cycle due to begin? (Always allow five days for menstrual cycle. Because of water retention and for your own personal comfort, you should avoid hair removal two days before your cycle is due and two days after it is completed.) Please enter your answer here.

Please note that waxing does have certain side effects such as skin removal, redness, swelling, tenderness, etc.

Initial Here

I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment. 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 my 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. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product / post-treatment care, I will consult the esthetician immediately. 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 the esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today. * Please click the yellow area and provide your initials here.

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Please Enter Date *

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