PLEASE FILL OUT OUR MEDICAL FORM BEFORE YOUR VISIT

First name

Last name

Phone

Birthday

Month

Day

Year

Yes, subscribe me to your newsletter.

How did you hear about The Polished Peach?

Referred By:

Within the last year have you been under a dermatologist's care?

Yes

Do you have any skin problems pertaining to your face/body?

Yes

If yes to either above, please specify:

Have you had any of the following in the last 7 days?

Chemical Peel

Laser Resurfacing

Microdermabrasion

Tanning Booth

If yes to either above, please specify:

*WARNING* Using retinoids (Accutane or similar) can cause skin to rip off during the waxing process. For your safety, we cannot wax you until you have been off of Accutane or similar for at least 6 month’s.

I understand

Do you burn easily in moderate sunlight?

Yes

Have you shaved within 10 days of your appointment date?

Yes - I understand some hairs may be missed if they are too short.

If yes, please specify:

Are there any illness or conditions for which you are presently being treated by a medical professional that we should be aware of?

Yes

If yes, please specify:

I have read and agree to these terms:

The paragraph below explains the liability waiver for The Polished Peach Co. By signing your name below, you agree to hold The Polished Peach Co. and staff harmless from all liability associated with waxing, and skin care treatments.

I have completed this form to the best of my ability. I will consult with my esthetician regarding any medicine I am currently taking and any skin tendencies that may be problematic. I give permission to my esthetician to perform the waxing procedure, or skin care procedure and will hold her, her staff, and The Polished Peach 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 have read and understand the post-treatment home care instructions. I am willing to 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 home product / post-treatment care, I will consult with the esthetician immediately. 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 liability waiver and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks.

Date

Month

Day

Year

eSignature.

Minors under the age 18 must have parent/legal guardian consent.

Signature

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Parental/Guardian Consent

I am the legal parent or guardian of the above minor and give my permission for them to receive the following services from The Polished Peach:

Print Parent/Guardian name here:

Signature

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Booking Policies

I have read and agree to the following late/no show/ cancellation/ reschedule policies:

Late Arrival Policy

I am so grateful for your business and want every visit to be a great one! To keep things running smoothly for all clients, I ask that you arrive on time for your appointment.

If you're more than 10 minutes late, I may not be able to complete all or any of your services and may need to reschedule you.
If I haven’t heard from you by 10 minutes into your appointment, it will be considered a No-Show and you’ll be charged 50% of your scheduled service.

Cancellation Policy

To respect everyone's time, I kindly ask for at least 24 hours' notice for cancellations or rescheduling.

No-shows or late cancellations make it hard to rebook that time and impact both me and other clients waiting to get in.

I understand life happens, so I'll always use discretion—but please keep in mind:

No Call / No Show: 50% of your scheduled service
Late Cancellation/Reschedule (under 12 hrs): $20 fee

Thanks so much for your understanding and continued support! 💛