CLIENT INTAKE 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
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.
Comments
This field is for validation purposes and should be left unchanged.

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

CLIENT INTAKE FORM

LOCATED IN MIDTOWN SANTA CRUZ

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