Patient Intake Form

Review the skin types below, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approach your treatment(s):*

Are you of Asian heritage (Class V) and/or have a history of keloid scarring?

YesNo

How would you describe your skin?

NormalOilyDryCombination

Please check off the products you use regularly

When were you last exposed to the sun (including tanning beds)?

Do you use sunless tanning products?*

YesNo

If yes, when was it last applied?*

Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?*

YesNo

If yes, which?

Do you form thick or raised scars from cuts or burns?

YesNo

Have you had laser treatments in the past?

YesNo

What body area was treated?

Any reactions?

Have you used Accutane in the past year?*

YesNo

Have you ever had injectables?*

YesNo

If yes, which?*

What facial area(s) and when?*

Do you currently use any retinol or retinoids or hydroquinone (Tretinoin, Retin-A, Differin, Adapalene, Tazorac)*

YesNo

If yes, which?*

Are you using any other topical creams, lotions, or oral antibiotics for acne, cancer. antiaging or hyperpigmentation?*

YesNo

If yes, which?*

Are you currently on Tetracycline or Minocycline, or have taken it in the last week?

YesNo

Have you used any of the following hair removal methods in the past six weeks?

WaxingThreadingDepilatoriesLaser Hair Removal

Have you had chemotherapy in the past 6 months?

YesNo

Have you ever had a reaction at the dentist or any other time from numbing?

YesNo

Do you have any allergies to medications, food, latex, topical products, and/or other substances?*

YesNo

If yes, please list.*

Do you have any of the following conditions:

Have you consumed drugs or alcohol in the last 24 hours

YesNo

Have you undergone any recent surgery?

YesNo

If yes, please explain

Please list all vitamins and supplements including herbal remedies you take regularly

Please list all current medications including aspirin, ibuprofen, blood thinners, etc. you take regularly

Is there anything else you would like us to know?

Risks of Care: I understand that the following problems may occur with treatment:

Scarring: This treatment can create a bruising and a moderate burn or blister to the skin. For an effective treatment, the power (joules) needs to be just below the blistering point which means skin will be red. There is a risk of scarring.
Pigmentation: The treated area may become either lighter (hypo-pigmented) or darker (hyper-pigmented) in color. This is rare and is usually just temporary, however may become permanent.
Infection: Although infection following this treatment is unusual, bacterial, fungal, and viral infections can occur. Herpes Simplex virus infections around the mouth can occur following a treatment, even if there is no past history of Herpes Simplex virus infections in the mouth area. Clients with a history of Herpes Simplex virus in the treated area are encouraged to seek preventative therapy. Should any type of skin infection occur, additional treatment, including antibiotics, may be necessary.
Bleeding: Pinpoint bleeding is rare but can occur following some laser treatment procedures. Should bleeding occur, additional treatment might be necessary.
Skin tissue pathology: Energy directed at skin lesions may potentially vaporize the lesion. Laboratory examination of the tissue specimen may not be possible. Only clearly benign pigmented lesions can be treated. A doctor’sclearance should be obtained in the case of this type of treatment.
Allergic reactions: In rare cases, local allergies to tape, preservatives used in cosmetics or topical preparations, have been reported. Systemic reactions (which are more serious) may result from prescription medicines. Allergic reactions may require additional treatment. Due to skin surface disruption, irritation and histamine reactions may also occur resulting in itching, dermatitis, or other forms of sensitivity.
Vision Damage: I understand that exposure of the eyes to light during the procedure could damage vision. I will keep the proper eye protection on at all times.

Consent*

I elect to receive the laser/light energy system procedure(s) indicated above for the stated benefit intended. I understand that outcomes may vary, including 1) good results in one session; 2) good results but only after additional sessions; 3) no results; and in rare cases 4) adverse results. I understand that other treatments to enhance outcomes may be recommended, including, but not limited to, the application of skin care products.Pre-Procedure and Aftercare Instructions: I have received, and will strictly adhere to, all pre-procedure and aftercare instructions. I understand that for those with more color in the skin, it is advised to use a lightening agent leading up to the procedure to suppress the melanin in the skin. I understand there may be an extended period of recovery following the procedure(s), and that aftercare compliance is crucial for healing, prevention of scarring, hyper-pigmentation and hypo-pigmentation. I understand that particularly avoiding sun exposure after the procedure is crucial to reduce the risk of color change and will always apply a broad spectrum SPF 25 or higher, as recommended by my technician. I understand that initially, the skin treated may be red and swollen, that fine, thin scabs may form, and that the healing process typically takes anywhere from one to three weeks. However, I am aware that in rare cases, depending on my skin sensitivity and recovery capacity, healing could take as long as three to six months.I certify that this consent has been fully explained to me, that I have read the above paragraphs, and that I elect to receive the laser/light energy procedure(s) indicated above. I understand the various risks associated with the Procedure(s) and the importance of properly following pre-procedure and aftercare instructions to minimize those risks. I consent to my photograph being taken before and after the procedure(s).I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that it is my responsibility to inform the esthetician of my current medical or health conditions and to update this history. A current medical history is essential to execute appropriate treatment procedures. By proceeding to use our products, treatments, services and facilities, you represent to us that you are in good health and physical condition to use such products, treatments, services and facilities safely, and fully except the risk associated with doing so. You confirm (to the best of your knowledge) that the answers you have given are correct and that you have not withheld any information that may be relevant to your treatment. You are aware that there often inherent risks associated with skin care or massage services and that the service that you are about to receive could have unfavorable results including but not limited to allergic reaction, irritation, burning, redness, scarring, or soreness. By signing below, you further agree that you will not hold glowlaboratories llc (DBA Glow Labs Facial Bar), or its affiliates, or any of its employees responsible for discomfort, unfavorable outcome or result, damages, losses, injury, illness or death howsoever caused arising out of or in connection with use of the products, treatments, services and facilities at glowlaboratories llc (DBA Glow Labs Facial Bar) (save in respect of death or personal injury arising out of the gross negligence of glowlaboratories llc (DBA Glow Labs Facial Bar) or its employees).All clients of Glow Labs Facial Bar must secure their personal belongings and refrain from leaving cash, jewelry, or valuables of any sort a glow labs and other parts of the promises. Glow Labs Facial Bar shall not be liable for any damage, loss, theft or disappearance of any property brought to the premises.

Client Name (Printed)*

Client Name (Signature)*

Date*

Date

Esthetician

FACIAL/CHEMICAL PEEL/MICRONEEDLING INTAKE

HEALTH HISTORY

LASER INTAKE FORM

HEALTH HISTORY

MASSAGE INTAKE FORM

SECRET RF INTAKE FORM

HEALTH HISTORY