Foot Spa Paraffin Wax Consent Form
Please complete this form to provide your consent and help us ensure your safety during your paraffin wax foot spa treatment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Treatment
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Do you have any of the following conditions? (Select all that apply)
*
Open wounds or sores on feet
Skin infections or rashes
Allergies to paraffin or related products
Poor circulation or neuropathy
Diabetes
None of the above
Other (please specify)
Signature
*
Submit Consent
Submit Consent
Should be Empty: