Wax Waiver

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Appointment Date

Select all that apply

I have used alpha hydroxy acid or glycolic in the past 72 hours

I am currently using Retin-a, Renove or Accutane

I was exposed to sun or tanning beds in the last 24 hours

I am using a skincare product or medicine that can thin blood

I am diabetic

I bruise easily

I am taking medication that recommends staying out of the sun

I am pregnant

If any options above applied to you, or if you have any questions, please elaborate

Drinking caffeine, alcohol, being stressed, close to your period or pregnant can make you more sensitive. Please note that waxing can have certain side effects such as redness, tenderness, and swelling. Due to some medicines, products, or skin sensitivities, skin lifting could occur. This is not a common occurrence, but it is a possibility.

I declare that the info I’ve provided is accurate & complete. I have read the above information and have given an accurate account of the questions. 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 harmless from any liability that may result from this treatment. I understand that my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible.

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Today's Date

Thanks! See you soon, gorgeous!

Wax Waiver

BENDOVER WAX STUDIO & BEAUTY BOUTIQUE

550 SW INDUSTRIAL WAY, SUITE 154

BEND, OR 97702

PHONE: 541-728-1617