New Client Consultation Form:

Please fill out the following information so we can provide you with the best possible care. Thank you!

New Client Intake

Name
MM slash DD slash YYYY
Address
Have you ever had chemical peels, laser or microdermabrasion?
Have you received any of the above services in the past month?
Do you use Retin-A, Renova, or Retinol/vitamin A derivative products?
Have you used any of these products in the last 3 months?
Have you used an acne medication in your lifetime?
What skincare products are you currently using?
Have you used any of the following hair removal methods in the past six weeks? Check all that apply.
What areas of concern do you have regarding your: Skin: (Please check any that apply)
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Have you had any recent tanning bed or sun exposure that changed the color of your skin?
Have you experienced Botox, Restylane or Collagen injections?
Female Clients Only: Are you taking oral contraceptives?
Are you pregnant or trying to become pregnant?
Male Clients Only: What is your current shaving system?
Do you experience irritation from shaving?
Do you experience ingrown hairs?
I understand and have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand that withholding information 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 this institution and/or skincare professional from liability and assume full responsibility thereof.

Cancellation Policy:

Must notify at least 48 hours’ notice for cancellations and changes to your scheduled appointment.

We understand that sometimes schedule adjustments are necessary, therefore, we request at least 48 hours’ notice for cancellations and changes to your scheduled appointment.

Your appointments are reserved especially for you. When you forget or cancel your appointment without giving at least 48 hours’ notice, We miss the opportunity to fill that appointment time with clients on the waiting list.  This will allow us to better serve everyone.

Understand that even when you cancel within the policy allowance that does not mean that your spot can be filled. Please schedule your appointments accordingly, so it does not interfere with your other obligations. 

As a small business, it is difficult and we cannot operate this way and provide superior services to all our clients. 

If you have given too many late notice cancelations, Pure Skin Care will not be able to continue providing services to you. You will not be rescheduled.  

As a courtesy, email reminders are sent one week before your appointment and a text message reminder 48 hours in advance.  Please make sure your email and phone number are updated with us.

It is your responsibility to remember your appointment dates, times. Please avoid late arrivals and missed appointments.  Since the services are reserved for you personally, a cancellation fee will apply as noted below. In the event that we do not receive the required notice for cancellation, the following fees will be billed via square invoice.

Less than 48-hour notice or a no-show will result in a charge equal to 50% of the reserved service amount.

We appreciate you supporting our small business. 

Live Beautifully,

Erin Brinton