Waxing Intake Form

Personal Information
Please help us ensure a safe and comfortable waxing experience by providing the following information:
Do you have tendencies toward any of the following?
Are you taking or have you ever taken or used topically?
Medical Data:
Are you taking any type of Antibiotic, Birth Control, Hormone Replacement or Blood Thinners?
Please read and initial the following information about contraindications:
Anyone showing signs of redness, rash, open and or abraded skin, an active lesion of Herpes Simplex I or II, sunburn (either from natural sun exposure or a tanning bed), psoriasis or eczema cannot receive waxing services. Anyone Currently using or have used in the past five days the following medications: Retin-A, Renova, Differin, or Avita cannot receive waxing services.
Anyone having just received  Microdermabrasion, Laser treatment or an Acid Peel cannot have a waxing service on the same area.
Post Care Instructions:
The area of skin that will be waxed may or may not be sensitive for 24-48 hours afterward. Avoid any low pH products on that area such as Retin-A, Glycolic/Salicyclic Acids, topical acne preparations such as Benzyl Peroxide, and the like for up to 48 hours. Avoid exercise for 24 hours as perspiration can cause prolonged redness, irritation, and may cause stinging. Avoid direct sun exposure to the treated area(s) and be sure to wear sunscreen as always but particularly on the treated area when outdoors.
 I have read the above contraindications and the related pre and post instructions pertaining to the professional services I am about to receive, and do therefore agree to waive the liabilities towards White Lotus Day Spa and practicing licensed aestheticians, for injury or damages. I confirm that the above mentioned contraindications for my services today do not apply to me.
If at any time there are changes in the information given, or in my condition, I will notify my esthetician and upgrade this form before receiving additional waxing services. I release the practitioners and their insurers, and their respective officers, directors, stockholders, successors, employees, and agents from all liability of any nature whatsoever, whether past, present, or future, for injury or damage which may occur to myself or my family as a result of my receiving  waxing services.
I agree that inputting my full name above acts as an electronic signature. The information above is accurate.

Thanks for submitting!