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The Naked Peach Waxing Boutique Waxing Release Form

Today's Date: January 17, 2021

Please note: Waxing and threading does have certain side effects such as skin removal, redness, swelling, tenderness, bruising, etc. I have read the below information and if I have any concerns, I will address these with my technician. I give permission to my technician to perform the waxing and or threading services I am requesting and will hold him/her and The Naked Peach Waxing Boutique harmless from any liability that may result from waxing and or threading treatments. I have given an accurate account of the questions below and they have been answered truthfully and completely to the best of my knowledge. I understand the below questions and have had sufficient opportunity for discussion to have any questions answered. I understand the waxing and threading procedures and accept the risks.

 

Please select who will be participating...
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First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

We only do brazilian/manzilian-bikini/mankini over 18 years of age.

Have you ever been treated for cancer?*
No
Yes

if yes, when and what type of therapies?
Are you Diabetic?*
No
Yes
Have you used any type of acid or chemical peel in the past 48 to 72 hours?*
No
Yes
Are you using Retin A, Renova or Accutane?*
No
Yes
Are you using any other skin thinning products and or drug?*
No
Yes
Have you sun bathed in the past 72 hours?*
No
Yes

Please list all medications:
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

We only do brazilian/manzilian-bikini/mankini over 18 years of age.

Have you ever been treated for cancer?*
No
Yes

if yes, when and what type of therapies?
Are you Diabetic?*
No
Yes
Have you used any type of acid or chemical peel in the past 48 to 72 hours?*
No
Yes
Are you using Retin A, Renova or Accutane?*
No
Yes
Are you using any other skin thinning products and or drug?*
No
Yes
Have you sun bathed in the past 72 hours?*
No
Yes

Please list all medications:
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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