Due to the 2019-2020 outbreak of the novel Coronavirus, COVID-19, we are taking extra precautions with the intake of each client, health history review, as well as sanitation and disinfecting practices. Please complete the following and sign below.

Symptoms of COVID-19 include:
• Fever
• Fatigue
• Dry Cough
• Difficulty Breathing

I agree to the following:
• I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
• I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the last 30 days.
• I affirm that I, as well as all the household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.
• I affirm that I, as well as all the household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a "hot spot" for COVID-19 infections within the last 30 days.
• I understand that this business and my therapist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client. Symptoms Of COVID-19

By signing below, I agree to each above statement and release the employees and GLOW FACIAL BAR, LLC from any and all liability, and for the unintentional exposure or harm due to COVID-19. Your esthetician, cosmetologist, or lash technician and all team members of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Please read ALL of the following statements carefully and indicate your understanding and acceptance by signing below:

• I understand that my facial treatment may include clinical-strength products, extractions, microcurrent, high frequency, LED light therapy, oxygen therapy, and other treatment modalities as necessary.

• I understand that this is a cosmetic treatment and that no medical claims are expressed or implied. I understand that to achieve maximal results, I may need more than one treatment and I need to follow the maintenance home protocol.

• I understand that there are no guarantees as to the result of this treatment, due to many variables such as age, conditions of the skin, sun damage, smoking, and climate. I may or may not experience results as each case is individual.

• I understand that there may be some degree of discomfort, i.e. stinging, “pin-pricking” sensation, hotness or tightness

• I understand that although complications are very rare, sometimes they may occur and that prompt treatment is necessary. In the event of any complications, I will immediately contact a member of the GLOW Facial Bar, LLC staff.

• I will reveal any medical conditions that may affect the treatment such as pregnancy, cold sore tendencies, allergies, recent facial peels, laser or surgery, any types of contraindicated medications such as Accutane, hormone replacement therapy, steroidal medications or Retin-A related products such as Tretinoin. I acknowledge that I have not been on Acutance (acne medication) in the past 6 months.

• I give permission for photographs to be used by the GLOW Facial Bar, LLC staff for monitoring my treatment progress.

• Prior to receiving treatment, I have been candid in revealing any condition that may have an effect on this procedure. I will also inform GLOW Facial Bar, LLC of any changes in my medical history, current medications, and/or any changes relevant to this procedure prior to any future treatments.

• I have read the contents of this consent form carefully and I fully understand it. I have been given the opportunity for discussion pertaining to the treatment and all my questions have been answered to my satisfaction. I hereby release GLOW Facial Bar, LLC, and any of its employees against any and all liability associated with this procedure. I have been adequately informed of the risks and benefits of this treatment and wish to proceed with the treatment.


DERMAPLANING:

Please read the following statement carefully and indicate your understanding and acceptance by signing below:

I, the client, give my consent for the following procedure: dermaplaning to be performed by an Esthetician. Dermaplaning is a physical/mechanical form of exfoliation using a specialized dermaplaning blade for the removal of built-up dead skin cells and vellus hair. Following treatment, skin will be smoother, softer, and better able to absorb the active ingredients in treatment and home care products. I understand this treatment involves the use of the sterile, surgical blade to remove dead skin cells and vellus hair. As with the use of any sharp instrument, there is the possibility of nicks or cuts. I understand there are contraindications to this treatment, including but not limited to, diabetes (not controlled by diet or medication), cancer, active acne, bleeding disorders, the inability for blood to coagulate, or the development of keloids following injury. Certain medications including blood thinners, higher doses of Aspirin, and Accutane are contraindicated for this treatment due to the possibility of delayed clotting from a nick or cut. I certify that I am not taking any of the above medications or experiencing any of the above conditions. While every precaution will be taken to avoid nicks, cuts, and scratches, I understand the risks and consent to treatment today.

By my signature below, I give consent to receive treatments at GLOW Facial Bar, LLC, and have read and completed this questionnaire truthfully. I understand I will be receiving a professional service from a licensed Service Provider. I further understand that the Service Provider neither diagnoses illness, disease, or any other medical, physical, or mental disorder. I am responsible for consulting a qualified physician for any ailment that I have. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. If any information changes between my appointments, I will let my Service Provider know. I understand that there shall be no liability on the Service Provider or GLOW Facial Bar, LLC for any services rendered.

Please read ALL of the following statements carefully and indicate your understanding and acceptance by signing below:

CONTRAINDICATIONS TO ALL PEELS:
If you have any of the following, a peel should not be done at this time and you must notify your Skincare Specialist immediately:

• Use of Accutane in the last 6 months
• Active herpes simplex (cold sores)
• Facial wards
• If you are now pregnant, think you might be pregnant or are trying to become pregnant
• If you form keloid or hypertrophic scars
• If you had a history of sun allergies
• Prior bad reaction to a peel
• Recent radiation treatment for cancer
• Sunburn or significant sun exposure in the last two days
• Surgery or cryosurgery within the last month to the area that you plan to have peeled
• Allergic to Resorcinol
• Allergies to salicylic acids
• Blood vessel disease
• Diabetes
• Inflammation, irritation or infection of the skin
• Influenza
• Varicella (chickenpox)
• Kidney or Liver disease


WHAT TO DO BEFORE YOUR PEEL:
1. Do not apply Retin-A, Renova, Tazorac, and/or Differin 2 weeks prior to and 2 weeks after your peel, to the treatment area, or as instructed by your Skincare Specialist at GLOW Facial Bar.
2. Do not suntan or use the tanning bed 2-4 weeks prior to and 2-4 weeks after your treatment.
3. Stop any type of depilatory treatments (waxing, depilatory creams) to the area of treatment, 2 weeks prior to and 2 weeks after your peel.
4. Stop electrolysis, and any type of laser treatments (laser hair removal, IPL) to the area of treatment, 2-4 weeks before and 2-4 weeks after your peel or as instructed by your Skincare Specialist at GLOW Facial Bar, LLC.


POST TREATMENT CARE:
1. When cleansing, do not scrub. Use a gentle cleanser directed by your Skincare Specialist at GLOW Facial Bar, LLC.
2. With any peel, your skin may start to peel 1-3 days after the peel and continue to peel for 2-5 more days; however, it is also possible your skin may not peel at all.
3. Do not peel, pick, or scratch the treated area, as this may result in scarring.
4. Apply polysporin, bacitracin, or Vaseline to dry flaky areas or as directed by your Skincare Specialist at GLOW Facial Bar, LLC.
5. Do not have any other facial treatments for at least 2 weeks after your peel or until the skin is smooth and back to normal.
6. If given a cortisone cream by your Skincare Specialist,
please apply it 1-3 times per day to red irritated areas or as directed. Follow any additional and all instructions given to you by your Skincare Specialist.
7. Always wear your sunscreen; apply a sunscreen with SPF 30 every morning


AFTER PEEL:
• Patients may have tightness and smoothness immediately post-peel. You may experience peeling 1-2 days after treatment and can extend up to 7 days. Minor side effects may include, but are not limited to superficial crusting, edema and temporary bruising in the lower eyelid areas, hypopigmentation, temporary dryness and hyper-pigmentation, all which typically resolves quickly


STATEMENTS:
• The Skincare Specialist at GLOW Facial Bar, LLC has explained to me the treatment process and it may include various acids which are called chemical peel. I understand that side effects may include, but are not limited to, increased color, decreased color, infection, pain, bleeding, swelling, scarring or damage to nearby structures, nerves, drug reactions, or unforeseen complications.
 
• I am undergoing this peel in an effort to improve my skin texture and color. I understand I may achieve some improvement in my fine wrinkles as well, but no guarantee has been made to me regarding my level of improvement from this peel. The Skincare Specialist at GLOW Facial Bar, LLC has explained to me that I may need several of these peels to achieve optimal results.
 
• I understand that there is a possibility that this procedure will fail or be unsuccessful or need to be repeated or may require additional treatment of complications
 
• I have read the instructions provided as to how to care for my skin prior to and following this Procedure and agree to abide by it. I understand that proper sun protection including, but not limited to, the faithful use of broad-spectrum UVA-UVB
sunblock with SPF 30 is vital to proper aftercare and the reduction of risks of undesired side effects.
 
• I understand my responsibility for properly fulfilling the appropriate aftercare instructions as explained by the Skincare Specialist at GLOW Facial Bar, LLC. I hereby release and hold harmless my Skincare Specialist, GLOW Facial Bar, LLC, and any of its employees, their suppliers from any consequences resulting from my failure to properly fulfill such aftercare instructions.

• Since multiple treatments may be required, this consent continues for all subsequent treatments by the Skincare Specialist at GLOW Facial Bar, LLC regardless of the time between treatments

• I am aware and acknowledge that there is a possibility of an allergic reaction. I have discussed thoroughly with my skincare specialist any such reactions and understand the care that would be necessary in the event of a reaction. I have had a chemical peel patch test done.
 
• I acknowledge that if I am prone to cold sores around the mouth, I will inform my skincare specialist and may need to use an anti-viral medication before the peeling treatment. (Peels may exacerbate the herpes virus.)
 
• I acknowledge that immediately after the peel, my face may appear frosted or sunburned and by day two, the skin may darken in color, feel tighter and be more sensitive. Days two through approximately seven, my skin may slough.
 
• I may experience some breakouts after the peel (for a period up to seven days) that normally disappear. Chemical peels make extractions of the comedones easier and the acne will ultimately improve if I continue treatment as directed by my skincare specialist.

• I acknowledge that pulling or picking skin may lead to infection or scarring.

• I am aware that on rare occasions the peel can penetrate deeper in certain areas, causing a crusted scab to form. I understand that if this area is not treated appropriately it could become infected and possibly lead to the formation of a scar. It is my responsibility to contact GLOW Facial Bar, LLC if any crusted areas form or if my skin does not look and feel completely normal within one week after my peel. I acknowledge this and desire that this product be applied to my skin.
 
• I understand and am willing to comply with all pre and post-care instructions. This procedure has been explained to me and my questions regarding such treatment, its alternative, its complications, and risks have been answered. I have been asked at this time whether I have any further questions about this procedure, and I do not.

• I understand the procedure and accept the risks, and request that this procedure be performed on me by a Skincare Specialist at GLOW Facial Bar, LLC. The information that I have been given has been in terms clear to me and I understand the risks and complications of the treatments. My questions have been fully and completely answered for me and I have read this document and understand its contents. I hereby give my unrestricted informed consent for the procedure.
 

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed above.

Please read ALL of the following statements carefully and indicate your understanding and acceptance by signing below:

LASH EXTENSIONS:
• I am not allergic to acrylates, cyanoacrylates, nail adhesives, tape, topical creams, and any other allergies pertaining to lashes.
• In the last 4 weeks, I have not had exfoliating, skin tightening, or skin-resurfacing facial treatments.
• In the past 6 months, I have not had eye surgery, wounds, or infections.
• In the past 6 months, I have not taken Retin-A, Acutance, or similar products.
• I do not have a history of eye disease, condition, injury, or surgery that affected hair/natural eyelash growth or loss.
• I acknowledge that there is no retention guarantee of lash extensions and that a number of factors can affect how long the lash extensions last. Such factors include but not limited to humidity, rubbing of the eyes, sleeping patterns, skin types, hydration and more. There will be no refund given after a service is performed due to the service already being completed.


LASH LIFT:
• I am not allergic to hair perming agents.
• I have not had a reaction to adhesive tape, gel pads, glycerin and castor oil, etc.
• I acknowledge that results can vary from client to client due to several affecting factors such as humidity, skin types, hydration, make-up use and more. Although effects usually last 4-8 weeks it may be less. A refund would not be granted due to results not being optimal due to services already being performed and staff being compensated.


LASH/BROW TINT:
• I am not allergic to hydrogen peroxide, paraphenylenediamine (PPD), hair dye or any agents in hair dyes.
• I have not had a reaction to adhesive tape, gel pads, saline, witch hazel, etc.


STATEMENTS:
• I understand that if I cancel my appointment within 24 hours of my scheduled time, I will be charged 50% of my scheduled services. If I “no-showed” for my appointment, I will be charged 100% of my scheduled appointment.

• I understand that lash services may have some inherent risk of irritation to the orbital eye area, including the eye itself, and could result in stinging and burning, blurry vision and potential blindness should the perming solutions enter the eye, or should an allergic reaction occur.

• I understand that some irritation, itching, or burning may occur on the skin if the perming solution comes into contact with it.

• I understand that if the perming solutions come into contact with my eye, my eye will be flushed with water and may be required to seek medical attention immediately.

• I understand that I will not get my lashes wet for the first 24 hours, avoiding any extreme heat such as sauna and steam for the first 48 hours.

• I understand that although the results are shown to last anywhere from 6-8 weeks, it will be different with each individual as due to varying factors like medication use, hydration, physical touch exposure, individual hair growth, natural hair shedding cycle and more.

• I understand while every attempt will be made to provide me with the lift/curl I have chosen, my final result may not be what I initially envisioned.

• I understand and agree to the care instructions provided by GLOW Facial Bar, LLC for the use and care of my lashes and brows. I realize and accept the consequences of failure to adhere to these instructions may cause different results. I understand and agree to that NO WATER CAN COME IN CONTACT WITH THE EYE AREA FOR 24 HOURS AFTER APPLICATION.

• I agree and consent to having my eyes closed and covered for the duration of the 45-75 minutes procedure.

• I understand that it is imperative that I disclose all of the information on my health that could be affected with this procedure. I have mentioned all conditions and circumstances regarding my health history, medication being taken, and any past reactions to products or medications.

• I understand that additional conditions could occur or be discovered during the procedure which could affect my ability to tolerate the procedure.

• I consent to “before and after” photographs for the purpose of documentation and potential promotional/advertising purposes.

• This agreement will remain in effect for this procedure and all future procedures conducted by GLOW Facial Bar, LLC.

I have read and fully understand all information in this agreement. I am over 18 years of age and consent to the agreement and to proceed. I understand that if I have any concerns, I will address these with my lash technician. I give permission to GLOW Facial Bar, LLC and its lash specialists, to perform the lash extension, lift, tint, or brow tint procedure we have discussed and will hold him/her and GLOW Facial Bar, LLC harmless and nameless from any liability that may result from this treatment. I have accurately discussed all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand GLOW Facial Bar, LLC and my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event, I may have additional questions or concerns regarding my treatment. I will consult GLOW Facial Bar, LLC immediately. I agree that this constitutes full disclosure and that I will supersede any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold GLOW Facial Bar, LLC responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today

By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed above.

Please read ALL of the following statements carefully and indicate your understanding and acceptance by signing below:

• In the past 48-72 hours, I have not used any Alpha Hydroxy Acid (AHA) or glycolic products.
• In the past 6 months, I have not used Rein-A, Renova, or Accutane.
• I am not using any skin thinning products and/or drugs.
• I do not have cold sores or herpes active flare-ups.
• I understand that waxing does have side effects such as skin removal, redness, swelling, tenderness, etc.
• I have read the above information and if I have any concerns, I will address these with my skin therapist. I give permission to my therapist to perform the waxing procedure we have discussed and will hold her and her staff harmless from any liability that may result from this treatment.
• I have discussed with my skin therapist all known allergies, prescription drugs, or products I am currently ingesting or using topically that could affect this procedure. I understand that my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In case a change has occurred it is the responsibility of the client to disclose this information to Glow Facial Bar to prevent any adverse effects.
• I have read and understood the post-treatment home care instructions. I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.
• I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the esthetician and GLOW Facial Bar, LLC, responsible for any of my conditions that were present, but not disclosed at the time of this skincare procedure, which may be affected by the treatment performed today.


By my electronic signature below, I acknowledge that I have read and fully understand this agreement and all information detailed above.

Please sign name and choose the date below.