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5416 Roberts Street, Shawnee, KS 66226 ● 913.441.9090

Do you or are you prone to

Have you used any of the following in the last week?

Please read the following information carefully.

• Please note that waxing does have certain side effects, such as skin removal, redness, swelling, tenderness, etc.
• I give permission to my therapist to perform the waxing procedure we have discussed and I will hold them and their 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 therapist will take every precaution to minimize or eliminate negative reactions as much as possible.
• I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.
• I certify that I have read, and fully understand the above statements and that I have had sufficient opportunity for discussion to have any questions answered.
• I understand the procedure and accept the risks.
• I will not hold the therapist responsible for any of my conditions that were present, but not disclosed, which may be affected by the treatment performed.

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all the information detailed above.