• Client Intake Form

    Please provide your personal information below. Thank you!
  • Format: (000) 000-0000.

  • SKIN

  • What is your skin type? *
  • Have you been under the care of a dermatologist within the past year? *
  • Have you been diagnosed with any of these skin conditions? *
  • What areas of concern do you have regarding your skin? *
  • What skin products do you use on a daily basis? *
  • Do you experience frequent breakouts? *
  • Have you received any of these facial hair removal services in the last 7 days? *
  • Have you used Retinol, Retin-A or other Vitamin A in the last 7 days? *
  • Have you ever received chemical peels or laser services? *

  • Medical History for Contraindications

  • Have you experienced any of these contraindication in the past or present? *
  • Do you have any of the following *
  • Do you have any known allergies? *
  • Have you received Botox, Restylane, or Collagen injections in the last 6 months? *
  • What is your stress level? *

  • Pregnancy

  • Are you taking birth control? *
  • Are you pregnant or breastfeeding?
  • Are you trying to become pregnant?

  • I acknowledge that I must adhere to Island Glow Beauty's policies. I understand that cancellations must be done with at least 24 hours notice. Failure to do so will result in a 50% service charge to the credit card held on file. I acknowledge that ANY no show will result in a full 100% service charge fee to the credit card held on file.  I understand that after 15 minutes of tardiness my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.

  • I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions and it is my responsibility as a client of Island Glow Beauty to let them know before my services. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I understand the importance of following post care instruction after treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments I release Island Glow Beauty and License Esthetician of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

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