Intake Form

Name

First NameLast Name

What is your date of birth (MM/DD) ?

Are you 18 years of age, or older?

If under the age of 18, parental consent required

Phone Number

Area CodePhone Number

Have you had a facial before?

What are your specific skincare concerns?

Any other reasons for a facial besides your concerns?

Give us an idea of what you typically use on your skin daily?

Any known allergies?

Glow & Ink Aesthetics, LLC uses products in facials that may contain tree nuts, gluten and dairy, beeswax or have been manufactured in a plant with these ingredients.

Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

Are you currently using any products that contain:

Do you currently have any rashes, itching or underlying redness on your face?

Please list medications or supplements you are currently taking.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Have you had any surgical or non-surgical procedures?

If yes, where on your body was the surgery performed?

Have you had botox in the past 7 days?

Have you had fillers in the past 14 days?

Have you experiences any of these health conditions in the past or present?

Are you taking birth control?

Are you pregnant or breast-feeding?

I consent to Glow & Ink Aesthetics, LLC to use my photos/videos for their business purposes in all media aspects.

Acknowledgement and Waiver

I hereby agree to have this treatment be performed on me. I am aware that products used in facials and homecare may contain tree nuts, dairy and gluten. I acknowledge that the estheticians at skin theory may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update Glow & Ink Aesthetics, LLC to any changes.

I acknowledge that the esthetician does not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Glow & Ink Aesthetics, LLC. I hereby release, discharge and waive any and all claims against Glow & Ink Aesthetics, LLC and each of their partners, or any person(s) performing services or applying any products at Glow & Ink Aesthetics, LLC, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

Signature

Date

Parental Guardian Signature(required if client is under the age of 18)

Date

Your Skin

Your Medical History