Facial Treatment Intake & Consultation Form

  • Facial Treatment

    Client Intake & Consultation Form
  • Gender*
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  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Skin Concerns & Goals

  • Please check any of the following that apply to you:*

  • Skin & Medical History

  • Please check any of the following that apply to you:*
  • Do you smoke?*
  • How do you heal after an acne breakout, cut or scratch?*
  • Do you tan in the sun or in a tanning bed/booth?*
  • Please select all that apply, the skin care products you are currently using:*

  • Enhanced Treatment Consent

  • I understand that facial treatments at Luminary Glow are customized based on individual skin conditions and the duration of the service selected. Treatments may include, but are not limited to, enhancements such as dermaplaning, carboxy therapy, oxygen infusion, enzyme therapy, or other advanced modalities deemed appropriate by my esthetician.

    I acknowledge that these procedures are designed to improve skin health and appearance, and that temporary sensations or reactions such as tingling, warmth, redness, mild sensitivity, or light flaking may occur as a normal response to treatment.

    I understand that my esthetician will perform a skin analysis and determine which enhancements are suitable for my skin type and condition at the time of service. I consent to the use of such enhancements and to the professional judgment of my esthetician in selecting and administering them.

  • Please check any add-ons you agree to receive as apart of your facial treatments:*

  • Photos & Marketing Consent

  • I understand and consent to photos being taken before and after my treatment for client records.*
  • I give Luminary Glow permission to use there photos for marketing purposes, including social media and promotional materials, with no identifying details shared.*

  • Acknowledgement and Waiver

  • I hereby agree to have this treatment be performed on me. 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 products 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, sensitivities, medications and answered all questions honestly on the above form and agree to update Luminary Glow as to any changes. I acknowledge that Luminary Glow does not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Luminary Glow. I hereby release, discharge and waive any and all claims against Luminary Glow or any person(s) performing services or applying any products, 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 after any service or products received on this and any future dates. I assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

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