• Format: (000) 000-0000.
  • Date of birth *
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Appointment *
     - -
    2 digit month, 2 digit day, 4 digit year

  • Tell me about your skin!

  • Is this your first facial?*
  • How consistent are you with your skincare routine?
  • Skin Type
  • How does your skin heal?
  • What are your current skin concerns ? Check all that apply*
  • Do you have any skin symptoms that cannot be seen or felt from the outside ? (Check all that’s apply)*
  • Have you had any recent treatments of the following within the last 2 weeks or month? Check all that apply (any injections need to wait a minimum of 2 weeks or until doctor/provider has advised it’s ok)*
  • Do you use Retin-A, Renova, Adapalene Hydroxyl Acid or Retinol/vitamin A derivative products? (If currently using Please avoid use 4-5 days prior to your treatment)*

  • Medical History

  • Are you currently under the care of a Doctor?
  • Are you currently Pregnant?
  • Do you have any allergies?

  •      Wellness / Life style / Diet 

  • How would you best describe your recent state of emotional wellness?

  •           Holistic Treatment Preferences 

  • What do you like most about during a treatment? (Please select all that apply)
  • I use Instagram for content creation, promotional and educational purposes. Do you consent of photos/ videos during your service?*
  • Do you prefer a Silent Appointment?

  • Client Consent Form & Liability Waiver

    Terms & Conditions

  • By signing below, I agree to the following:

    I have completed this form to the best of my ability and knowledge. I understand that my data will be strictly confidential. I agree to inform the technician (Larissa Ontiveros) of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician (Larissa Ontiveros) of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician (Larissa Ontiveros) and the salon for any injury or damages incurred due to any misrepresentation of my health.

  • Todays Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Photograph and Video Release

  • I hereby grant and authorize Lari Glam & Artistry (Larissa Ontiveros) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me to be used in and/or for any lawful promotional marketing materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive anyright to royalties or other compensation arising or related to the use of my image or recording. I hereby holdfrom all liability, petitions, and causes of action which

    I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Deposit Fee

  • Your appointment is valuable to me and my time is just as valuable. I will require a $25 non-refundable, non-transferable deposit upon booking to reserve your appointment. I will email/text an invoice and you have the option to pay via debit/credit card.  The remaining balance will be due on the day of your scheduled appointment. Forms of payment accepted for deposit/remaining balance: Card, Cash, Cash App, or Venmo.

    I have read and understood the Deposit Fee Policy and agree to abide by the above conditions. 

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Cancellation Policy

  • Your appointment and your time is very important to me. I understand that sometimes schedule adjustments are necessary. Therefore, I kindly request at least 24-48 hours' notice prior to your scheduled appointment time for cancellations or rescheduling of appointments. All cancellations/rescheduling will result in loss of deposit fee. Please remember that the deposit is to book your appointment. To cancel/reschedule: Please notify me via text: 620-417-0794 or email: lariglamartistry@gmail.com 

    It is mutually understood that if a cancellation is due to circumstances beyond any of our control, such as power outage, unfortunate incidence, illness, or weather that requires you or us to have to cancel or be closed during regular business hours, we will reschedule your existing appointment and no discount or rescheduling fee will apply. ALL "NO SHOWS" WILL BE CHARGED 50% OF THE FULL SERVICE AMOUNT. REMINDER, YOUR CARD ON FILE WILL BE CHARGED IF THERE IS A NO SHOW AND YOU WILL NOT BE ABLE TO BOOK WITH ME IN THE FUTURE. 
    I have read and understood the cancellation policy and agree to abide by the above conditions.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: