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Pure Wax & Beaute Bar
609-607-7873 

 

CLIENT INTAKE FORM 

CANCELLATION POLICY: Our schedule is dedicated to our clients and their needs, but when I have a no-show or last minute cancellation I cannot fill that appointment with another person. As a result I require at least 24 hours notification via text or phone to cancel an appointment. For reasons other than emergencies, any cancellation or no-show under 24 hours would incur a fee of $10 your first time. 

Signature agreeing to cancellation policy:

EYELASH EXTENSION
CONSENT, RELEASE AND WAIVER OF LIABILITY AGREEMENT 

I, the undersigned ("Customer"), consent to have synthetic eyelash extensions attached to my natural eyelashes (the "Service") by   and his/her/its staff, assistants, contractors and employees (collectively herein, the "Service Provider"). The Service and its associated risks have been explained to me by the Service Provider in terms that I understand. The explanation included:

  • The benefits of the Service;
  • The nature of the Service and how the Service will be performed;
  • The types of materials and adhesives used during the Service;
  • The most frequently occurring risks of the Service, and those risks which are unlikely to occur but which may involve serious consequences, including but not limited to the risk of experiencing: (a) Blepharitis and its associated symptoms, (b) an allergic reactions to the adhesive material used to attach the eyelash extensions to my natural eyelashes and to the synthetic eyelash material, (c) Traction Alopecia and its associated symptoms; (d) an eye injury due to synthetic and/or natural eyelashes falling on or into the eye; and (e) an eye or other injury occurring during the performance of the Service;
  • How to properly care for the synthetic eyelashes applied during the Service; and
  • How often I should expect to need to repeat the Service and the best methods for caring for the synthetic eyelashes after the Service is performed; and
  • Factors that affect retention of eyelashes.

I was given the opportunity to ask the Service Provider any questions I have regarding the Service and I have had those questions answered to my satisfaction. Based on the foregoing, I hereby assume all of the risks associated with the Service, whether known or unknown, including, but not limited to, the risk of personal injury or property damage. As consideration for Service Provider performing the Service, I forever release Service Provider and his/her/its respective directors, officers, members, managers, employees, agents, contractors, attorneys, representatives, successors and assigns from any and all actions, claims, or demands that I, my assignees, heirs, next of kin, spouse, personal representatives and legal representatives now have, or may have in the future, for injury, death, or property damage, in any way related to the Service. 

By initialing at the end of this paragraph, I grant Service Provider permission to reproduce, publish, distribute or otherwise use in any reasonable manner my name, photograph, likeness and statements, including, but not limited to, before and after pictures of my eyes and eyelashes in connection with the promotion of the Service or the products used in the Service (or other similar services and products) in all media, including without limitation, the internet, news articles, advertisements, or other electronic or printed materials. If my initials  are not present at the end of this paragraph, then the above-described permission has not been granted.

 

Dated: March 29, 2024

First Customer's Name

First Name*

Middle Name

Last Name*

Phone*
First Customer's Date of Birth*
First Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
First Customer's Signature*
Second Customer's Name

First Name*

Middle Name

Last Name*
Second Customer's Date of Birth*
Second Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Third Customer's Name

First Name*

Middle Name

Last Name*
Third Customer's Date of Birth*
Third Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Fourth Customer's Name

First Name*

Middle Name

Last Name*
Fourth Customer's Date of Birth*
Fourth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Fifth Customer's Name

First Name*

Middle Name

Last Name*
Fifth Customer's Date of Birth*
Fifth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Sixth Customer's Name

First Name*

Middle Name

Last Name*
Sixth Customer's Date of Birth*
Sixth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Seventh Customer's Name

First Name*

Middle Name

Last Name*
Seventh Customer's Date of Birth*
Seventh Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Eighth Customer's Name

First Name*

Middle Name

Last Name*
Eighth Customer's Date of Birth*
Eighth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Ninth Customer's Name

First Name*

Middle Name

Last Name*
Ninth Customer's Date of Birth*
Ninth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Tenth Customer's Name

First Name*

Middle Name

Last Name*
Tenth Customer's Date of Birth*
Tenth Customer's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
Customer'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.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

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. 


Who may I thank for sending you to me?

What services are you here for today?

What goals do you have for your lash service?

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

  • TO BOOK APPOINTMENTS PLEASE CALL 609-607-7873 

  • TO BOOK APPOINTMENTS ONLINE, VISIT www.purewaxbar.com 

Preferred Contact Method:*
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.


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