IN-GROWN AND DRY SKIN WAIVER FORM

Name: ________________________ Date: ______________

1. Are you currently affected by any of the following conditions?

Phlebitis _____ Diabetes _____ Sunburn _____ Allergies _____
Hypertension _____ Recent Surgery _____ Varicose Viens _____ Rash _____

2. Do you have any medical conditions, health problems or other physical conditions that
might affect the removal of the in-grown or dry skin service today?
YES: _____ NO: _____

If YES, Please explain: _________________________________________________

___________________________________________________________________.

IMPORTANTE NOTICE:

It is my choice to allow NAILANDIA Nail Studio and Body Spa to take out the in-grown
and dry skin of my nails. I hereby release NAILANDIA Nail Studio and Body Spa from
any claims resulting from such. Any information provided to me by NAILANDIA Nail
Studio and Body Spa is for general information and for educational purpose only and is
not intended for any medical or therapeutic purpose.

My signature below also indicates that I have stated any medications that I am
taking. In additional, I understand that it is my responsibility to update
NAILANDIA Nail Studio and Body Spa if any of the above-mentioned information
has changed.

____________________________ __________________
Signature Over Printed Name Date

Nailandia Nail Studio and Body Spa

Main Square Mall Branch