Client Intake Form

Client Details

Skin Care

Fitzpatrick skin types:
1) Very pale white skin, often with green or blue eyes and fair or red hair - burns without tanning
2) White skin, often with blue eyes - burns and does not tan easily
3) Fair skin with brown eyes and brown hair - burns first then tans
4) Light brown skin, dark eyes, and dark hair - burns a little and tans easily
5) Brown skin, dark eyes, and dark hair - easily tans to a darker color and rarely burns
6) Dark brown or black skin, dark eyes, and dark hair - never burns but tans darker

(Please list brand, product type and any description - you can also send a photo of what you currently use)


I understand, have read and completed this intake form truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from any treatments received. The treatments I receive here are voluntary and I release AESTHETICSBYTINA LLC from liability and assume full responsibility thereof.

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Photo and Video Consent

I, hereby grant and authorize TINA MCCONNELL (Aestheticsbytina LLC) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional 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 written or electronic copy.

Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

I hereby hold harmless and release TINA MCCONNELL (Aestheticsbytina LLC)  from 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.


Permissions granted for the pictures, video, and/or audio listed below:

Picture/Video/Audio Description: Before photos/videos, during the service photos/videos and after photos/videos                                                        

Date taken: Date the service is performed

Tap or click on the signature above to sign