Copyright 2011: G'nique's Spa Services | Brazilian Waxing. All Rights Reserved.
Located in the Historic Haymont District in Fayetteville, North Carolina
106 A Suite 3 Broadfoot Ave
Fayetteville, NC 28305
Please complete this form entirely. This will save on time when you come in for your appointment. CALL FOR AN APPOINTMENT BEFORE COMPLETING THIS FORM 910-494-3332
Have you ever had any waxing services?
Are you currently taking Accutane Retin-A, Tretinoin, Renova, Acne Medicine, or any other prescription or over the counter medications ?
Sensitive skin can burn from waxing procedures. Accutane and Retin-A or Tretinoin are drying to the skin, therefore, waxing may lead to removal of skin, which may cause scarring. Waxing over sunburned or very tanned skin may lead to removal of the skin, which may cause scarring. Allergies to any of the product ingredients used in waxing may cause severe allergic reaction. I confirm (to the best of my knowledge) that the information I have provided is accurate and complete. I have not withheld any information that may be relevant to my treatment and/or the results thereof. I am aware that there are often inherent risks associated with waxing procedures, and that the services I am about to receive could have unfavorable results including, but not limited to: allergic reaction, irritation, burning, redness, scarring, soreness, etc. By typing my name below, I further agree that I will not hold G’nique’s Spa Services, Genique Freeman, its affiliates or any of its employees responsible should there be any unfavorable outcome or result. Your typed name serves as an electronic signature you may be asked to sign this form when you come in for your initial and follow up services. Waxing is a service that can be uncofortable. Some clients are more sensitive than others but if you maitain a regular waxing regimen the discomfort will get better.
Please list any prescribed or over the counter medications?
Have been diagnosed with diabetes, allergies, or any STD?
Print Your First & Last Name
If you have any medical diagnoses or allergies please list and explain: