Inner Glow Skin Care Service Contact Form

Please enable JavaScript in your browser to complete this form.

General & Medical Information

Are you currently using Accutance?
Are you pregnant?
Are you nursing?
Do you have implants?
Do you smoke regularly?
Do you participate in vigorous aerobic activity or sports?
Have you ever had: cold sores/herpes/hives/keloids?
Do you wear contact lenses?
Do you wear sunscreen on a regular basis?
Have you visited a tanning booth within the past 3 weeks?
*If so, your service may have to be rescheduled.
Are you currently taking any antibiotics?
(may increase sensitivity)

Skin Care Related:

Are you currently using products containing
Have you ever used Hydroquinone (skin lightener)?
Do you currently use wax, electrolysis or depilatories on your face?

Have you ever had any of the following:

Chemical Peel?
Laser Resurfacing?
Collagen or Botox?
Facial Surgery?
Do you have permanent make up
To help us determine a facial regimen suitable for you, describe your skin type: (Check those that apply)
Skin Tone:
Hair Color:


If I experience any pain or discomfort during the session, I will immediately inform the esthetician so that the products and/or technique may be adjusted to my level of comfort. I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. I also understand that the Licensed Esthetician reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which facial
treatments are contraindicated.

We’re Ready to Personalize Your Skin Care Experience.