Wax Waiver Form

Name: ____________________________________________ Date: __________________

1. Have you ever had a professional waxing? YES: _____ NO: _____
2. Have you ever had an adverse reaction to waxing? YES: _____ NO: _____
If YES, please explain: ______________________________________________________
________________________________________________________________________.
3. Have you been undergoing skin peeling? YES: _____ NO: _____
4. Are you currently affected by any of the following condition?

Phlebitis _____ Diabetes _____ Sunburn _____ Allergies ____Rash _____

Herpes _____ Recent Peels _____ Menstrual Cycle _____ Distended Capillaries _____

Hypertension _____ Recent Surgery _____ Varicose Vein _____ Recent Scar Tissue _____

5. Do you have any medical condition, health problems, or other physical conditions that might affect
you waxing service today? YES: _____ NO: _____
If YES, please explain: ________________________________________________________
_____________________________________________________________________________.

6. Are you currently taking any medications? YES: _____ NO: _____
If YES, please explain: __________________________________________________________
____________________________________________________________________________.
Accutane _____ Retinol _____ Tetracycline _____ Renova ______
Defferin Gel _____ Retin A _____ Any retinoid medication _____

7. Have you recently take any blood thinner? i.e. Aspirin, Alcohol, Tylenol, Medication
YES: _____ NO: _____
If YES, please list: _____________________________________________________________

IMPORTANTE NOTE:

It is my choice to receive waxing. I understand that the information given above is strictly confidential and
will be used for no other purpose than to assist NAILANDIA Nail Studio & Body Spa in customizing my
waxing experience. I also understand that failure on my part to disclose information could result in injury
and/or illness and I hereby release NAILANDIA Nail Studio & Body Spa from any claims resulting from
such. Any information provide to me by NAILANDIA Nail Studio & Body Spa is for general educational
purposes only and is not intended for any medical or therapeutic purpose.

My signature below also indicates that I have stated any medications that I am taking. In addition, I
understand that is my responsibility to update NAILANDIA Nail Studio & Body Spa if any of the
above information has changed.

Nailandia Nail Studio and Body Spa

Main Square Mall Branch
Client Signature: _________________________________________ Date: ____________________

Nailandia Nail Studio and Body Spa

Main Square Mall Branch