The online beauty waiver system helps you collect and sort waivers easily.

Skincare

First and Last Name: * Please enter your name.

Date of birth: *

Please enter valid date.

Email: * Please enter your email.

How did you hear about us? * Please enter your answer here.

Lifestyle and Stress Analysis

Occupation: * Please enter your answer here.

Does your job require that you work outdoors? *

No.

Yes.

Please select at least one choice above.

How would you rate your stress level on a scale from 1-10? ? (Level 10 is highest) * Please enter your answer here.

How often do you exercise? *

1-3 times a week

4-7 times a week

once a month

never

Please select at least one choice above.

Are you a smoker? *

No.

Yes.

Please select at least one choice above.

Are you currently under the care of a physician? * Please enter your answer here.

If yes, for what condition? Please enter your answer here.

List all medications taken Please enter your answer here.

Allergies? If yes, please list. Please enter your answer here.

Are you *

pregnant

nursing

neither

Please select at least one choice above.

Do you have any metal implants in your body? *

Yes

Please select at least one choice above.

if yes, please list where Please enter your answer here.

Please check any of the following you have been treated for:

Skin Disease

High Blood Pressure

Diabetes

Cancer

Hormone Therapy

Acne

Cold Sores

Please select at least one choice above.

Your Skin

List 3 things you would like to change about your skin or reply n/a. * Please enter your answer here.

Have you ever had a facial treatment before? *

Yes

Please select at least one choice above.

How often do you wear facial sunscreen? *

Everyday

Occasionally

Only when I’m outside

Please select at least one choice above.

If you go in the sun without sunscreen, how often will you burn? *

Always

Most of the time

Sometimes

Rarely burn

Very rarely

I never burn

Please select at least one choice above.

How often do you use tanning beds? *

Never

Once a week

1-2 times a month

1-2 times a year

Please select at least one choice above.

What skin care line are you using? * Please enter your answer here.

Please list any cosmetic procedures you have had in the last 12 months Please enter your answer here.

Do you receive any of the following procedures regularly?

Facial waxing

Facial Injections

Microdermabrasion

Chemical Peels

Please select at least one choice above.

Your Treatment

Do you have a request/preference in music for your treatment? Please enter your answer here.

Would you like to enhance your treatment with any of the following? (Upgrade may require additional time)

Facial Waxing (Brows, Upper Lip, Chin wax) If time permits.

Add Decollete ($30-$45, depending on facial treatment)

Please select at least one choice above.

I understand, have read, and completed this questionnaire truthfully. I understand that this constitutes full disclosure and that it supersedes any previous written or verbal disclosures. I understand that withholding or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive here are voluntary and I release Apotheke Skincare & Wax Studio and my attending esthetician from liability and assume full responsibility from thereof.

Your signature *

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Please Enter Date *

Please enter valid date.