Loading...

Pure Wax & Beaute Bar
704-910-3069 

 

CLIENT INTAKE FORM

The following questions will help make our time together as effective as possible, and will help you become familiar with all the services we offer that may help you reach your beauty goals successfully.

Thank you for taking the time to share more about yourself with me today. I look forward to working with you as your waxologist/esthetician.

  • TO BOOK APPOINTMENTS PLEASE CALL 704-910-3069
  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

CANCELLATION POLICY: Our schedule is dedicated to our clients and their needs, but when I have a no-show or last minute cancellation we cannot fill that appointment with another person. As a result we require at least 24 hours notification via  phone  to cancel an appointment. For reasons other than emergencies, any cancellation or no-show under 24 hours would incur a fee of $10 on your first occurrence. Excessive late cancellations and no-show appointments will result in you being unable to book future appointments online you will need to call in the day you need service to see if we have availability to accommodate you. 

Signature agreeing to cancellation policy:

I have been off Accutane for at least 12 months 

I have not used Retin A, Differin Gel, or Retinova for 7 days

I understand that with treatment certain risks are involved and that any complications or side effects from known or unknown causes could occur. I freely assume these risks. I do not hold liable Pure Aesthetic & Beauty Bar LLC (DBA Pure Wax & Beaute Bar) or it's employees responsible for any condition which may or may not have resulted from experiencing services at the facility 

Dated: September 26, 2022

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Client's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Preferred Contact Method:*

How did you hear about Pure Aesthetics & Beauty Bar?

Who may I thank for sending you to us?

What services are you here for today? *
Have you ever been treated for cancer?*
No
Yes

If yes, explain:
Have you used any Alpha Hydroxy Acid or Glycolic products in the past 48-72 Hours?*
No
Yes

If yes, explain:
Are you using Retin A, Renova, Differin Gel or Accutane (oral form of Retin A)?*
No
Yes

If yes, explain:
Are you using any other skin thinning products or medications?*
No
Yes

If yes, explain:
Are you exposed to the sun on a daily basis or are you considering spending more time in the sun soon?*
No
Yes

If yes, explain:
Do you use a tanning bed?*
No
Yes

If yes, explain:
Are you currently taking medications?*
No
Yes

If yes, explain:
Have you had any cosmetic facial injections, peels, facial procedures or microdermabrasion within the past two (2) weeks?*
No
Yes

If yes, explain:

Please note that waxing does have certain side effects such as skin removal, redness, swelling and tenderness, etc. Pure Aesthetics & Beauty Bar LLC is not responsible for the aggravation of conditions, which were present, or conditions not disclosed to the practitioner, at the time of service. Pure Aesthetics & Beauty Bar LLC is not responsible for any condition, which may/may not have resulted from experiencing services at our facility. Thank you. 

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!