Wax Release Form
Wax Questionnaire
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First and Last Name *
Address *
Primary Phone *
Email *
Have you ever had a professional waxing before? *
Have you used a tanning bed in the past 48 hours? *
Are you currently affected by any of the following conditions? Please check all that apply.
If I have Herpes or MRSA, I may experience an outbreak. I understand I may carry Herpes and/or MRSA without any physical symptoms or having had a medical diagnosis confirmed. Please type your initials as an electronic signature that you understand the above. *
Are you currently taking or using any medication for your skin? *
If yes, you are using medication for your skin, please check all that apply.
Are you using any over the counter scrub, peels, anti-aging, anti-wrinkling creams or cleansers or products that contain retinol/acids? *
Do you have any tendencies to the following? Please check all that apply.
We reserve the right to refrain from providing a waxing service until written permission is given by your medical professional.
Important Note: (Please read carefully and thoroughly)
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 the spa / salon therapist in providing a suitable waxing session which would take into consideration to my specific requirements. Waxing may cause: Skin lifting, bruises, scabs, scarring, redness, hyperpigmentation, or pimples. Waxing of soft tissue may cause the skin to tear resulting in the need for stitches. I understand all of the above mentioned reactions. I also understand if I change my skin care routine or medications I must inform the professional PRIOR to starting any service in the future. I also understand that failure on my part to disclose information could result in injury and or illness and I hereby release Capretti & Co., LLC, from any claims resulting from such. Any information provided to me by the Spa / Salon therapist is for general purposes only and is not intended for any medical or therapeutic purpose.
Please type your full name as an electronic signature that you understand the above.
 *
Please enter the date you completed this questionnaire, then submit the form. *
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