Oasis Massage and Spa- Wax Form

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The following is for our records only. We will not sell or give out your information.

Full Legal Name: *

Mobile Number: *

Email: *

Address (including zip code) : *

Date of Birth: *

YYYY

Emergency Contact Name and number: *

Occupation:

How would you like to receive appointment reminders? *

Text

Both

Neither

How did you hear about Oasis?

Gift Certificate

Referral

Internet

Other:

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I have AT LEAST 1/4 inch of hair in the area I am looking to wax. *

YES

Required

Please mark any that apply:

Undergone treatment from a dermatologist or had any surgeries in the area you're planning to wax

Used Retin-A®/Renova® or powerful alpha hydroxy acids in the past 48-72 hours

Taking Accutane® or other medications

Using any topical medications

Had extended sun exposure or used a tanning bed in the last 32 hours

Have an open wound or sore in the area you wish to be waxed

Other:

Are you using any other skin-thinning products and/or drugs? IF YES, PLEASE LIST:

Allergies: *

Statement of Understanding

Please note that waxing can cause side effects such as skin removal, redness, swelling, tenderness, etc.

If I have any concerns, I will address these with my esthetician. I give permission to my esthetician 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 will 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 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 disclosure. I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, 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.

Date acknowledging the Statement of Understanding: *

YYYY

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