Client Intake Form
Please answer the following questions so that I am able to stay in touch with you and take better care of your needs. I will not share this information with anyone. It is for my use only.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Preferred Nickname *
Birthday
MM
/
DD
/
YYYY
Street Address *
City *
State *
Zip Code *
Phone Number *
Can I text you appoinment reminders and follow-ups to the phone number you provided? *
Email Address *
Would you like to be added to my email list for specials and updates? (Don't worry, I won't bombard your inbox) *
Occupation
Emergency Contact Name *
Emergency Contact Phone Number *
How did you hear about Pure Esthetics?
Clear selection
Photo/Video Release
As a small business, I utilize social media to promote my services. I don't want to do anything that makes you uncomfortable so I ask that you complete the following questions to let me know if i have your permission to use photos or videos, and whether or not you'd like to be identified. Thank you in advance.
I hereby authorize Pure Esthetics/Cindy Brazinski to use my photos and videos. I understand this may include social media, advertisement, promotional material, and/or other similar ways. My consent is freely given without expecting payment. *
I release Pure Esthetics/Cindy Brazinski from any and all liability that may arise from the use of my photos/videos. *
I prefer that: *
Required
I understand that I can revoke this release at any time and that the use of my photos/videos authorized by this release will immediately cease. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms