New Client Intake Form

This consultation form is to correctly evaluate your needs. All questions contained in this questionnaire is strictly confidential.


Name *
Name
Date of Birth
Date of Birth
Sex *
Cell Phone *
Cell Phone
Address *
Address
How did you hear about us?
Within the last year, have you been under a dermatologist's care?
Do you have any special skin problems pertaining to your face/body?
Have you had the following in the last seven days?
Are you currently using any products that contain the following ingredients?
Accutane Warning*** Using retinoids (Accutane or similar) can cause skin to rip off during the waxing process. For your own safety, we cannot wax you until you have been off of Accutane or similar medications for at least 6 month’s time. I understand the dangers of Accutane. Should I decide to take it in the future, I will inform my esthetician and will not get waxed at pure wax at any time within 6 months of taking the medicine.
Do you burn easily in moderate sunlight?
What is your current hair removal method?
Have you shaved within 10 days of your appointment date?
I understand that some hairs may be missed if they are too short.
Do you have or are you prone to:
Are there any illness or conditions for which you are presently being treated by a medical professional that we should be aware of?
The paragraph below explains the liability waiver for Pure Wax Brazilian Body & Brow Studio LLC. By signing your name below, you agree to hold Pure Wax LLC 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 Pure Wax 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.
Today's date
Today's date
Minors under the age of 18 must have a parent/legal guardian signature.