Online waiver | Waiver app - The World's Leading Digital Waiver Application

Please fill your name: *

Date of Birth: *(MM/DD/YYYY)

Address: *

Same as above

Phone number: *

Email: *

ADD ON SERVICE*

Foot Massage (15min) $20

Eyecare Lifting Treatment $20.

Lip Treatment $20

Anti-Winkle Neck Lifting $20

List of current medications:*

List of Allegies:*

Are you Pregnant?*

No

Yes

Do you wearing contact lenses?*

Yes

No

Are you wearing dentures?*

Yes

No

Have you ever had surgery?*

No

Yes

Please take a moment to carefully read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, certain esthetic treatments may be contraindicated. A referral from you primay care provider my be required prior to service being provided.

Your Signature*

Click to sign

Esthetician's Client Information Questionnaire

Esthetician's Client Information Questionnairee