Waxing Intake Form

Contact

Email(Required)

Phone(Required)

Date of Birth(Required)

History

When was your last wax?

When was your last facial hair removal?

What body part(s) would you like waxed today?

FEMALE GUESTS - When was your last menstrual cycle start date?

Have you ever been treated for cancer? If so, when?

List any other illness/condition you are presently experiencing or being seen by a doctor for:

If yes, please specify

If yes, when and how often?

If yes, which ones?

New use of any of the medications listed above increases the possibility of a reaction.
Please inform the Esthetician if you have begun taking any new medications since your last session.

Body/Facial Waxing Disclosure

I have read the above information and I have addressed any concerns with my Esthetician. I give permission to my practitioner to perform the waxing procedure we have discussed and will hold them 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.
I have read and understand the post-treatment home care instructions. I am willing to follow the recommendations made by my Esthetician for a home care regimen that can 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 my 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 LaVida Massage or the Esthetician responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.

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LaVida Massage of Fort Collins

LaVida Massage of Fort Collins