CLIENT FORM

Consultation Form

All prospective clients need to fill out this form. It is extremely helpful when determining the best approach for a successful procedure.

Please have an image ready to upload as it is required. If this is a problem, please contact Erika at staff@purebeautyesthetics.com or call 426-4321.

Erika will be contacting you within 72hrs.
Name

Last

Email*

Phone
Over 18 years old*

Yes

No
I am interested in the following procedure:
Eyebrows
Eyelids
Lips
Micro Needling
Other (Facials, Waxing)
Please list any medical, health and/or skin conditions/sensitivities
Please list any medications, including topical, prescriptions and vitamins you are taking
Please describe your desired outcome
Upload a image of yourself*
Accepted file types: jpg, gif, png, pdf, Max. file size: 400 MB.
Phone
This field is for validation purposes and should be left unchanged.
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LOCATED IN MIDTOWN SANTA CRUZ

Find us in our Seabright neighborhood between the cross streets of Federick and South Morrissey at 349 Gault Street, Santa Cruz.

Our hours are 9am – 6pm, by apppointment only, Tuesday through Saturday.
Tel: 831-426-4321

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CLIENT FORM

LOCATED IN MIDTOWN SANTA CRUZ

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