Client Consultation Form

Name ______Address ______

Zip code ______email______Phone ______

Would you like to have our specials e-mailed to you? ______How did you hear about glo? ______Who can we thank?______

What is your birthday? ______

Health Info.

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc……

Please list. ______

Are you currently being treated by a physician for any conditions? ______

Please list any medications that you are taking. ______.

Are you pregnant or nursing? ______What trimester? _____

Please list any surgeries in the last year. ______

Do you have any metal implants or a pacemaker? ______

Do you use a tanning bed? ______Do you use a sunscreen daily? ______

What SPF? ______

Ladies, please list first day of last menstrual period. ______

How many hours do you sleep at night? _____ Are you claustrophobic? ______

Nutrition/Lifestyle

How many 8 oz glasses of water do you drink daily? ______How many cups of coffee/other caffine? ______Do you exercise? ______How often? ______On a scale of 1-10, how would you rate your stress level today? ___

Do you take any vitamins or supplements? Please List. ______

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Skin Info.

Please put an X next to conditions that you are concerned with.

Dark spots on your skin or uneven skin tone, face or body __ Acne breakouts or congestion ___ wrinkles or fine lines___ Facial hair __ Body hair ___Thin or misshaped brows ___ Redness or Rosaccea __ Lack of Skin tone (firmness) ____ Stress _____ Cellulite _____ Rough skin or Keratosis Pilaris ____ Dry skin ______Sensitive skin ___ Dullness _____ Fading of lip color _____ Thinning lashes ___

Dark circles under eyes _____ Puffiness under eyes _____ Tired, droopy eyes ___

What would you like to accomplish with your treatment today? ______

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Do you currently cleanse your skin morning and night? ______What product do you use? ______Please also list any toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily. ______

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______Do you enjoy spending time on your skin routine, or do you prefer a very simplified approach?______Do you burn easily in the sun? ______

Do you get an oily shine throughout the day?______Would you consider your skin oily, dry or normal or sensitive? ______Do you enjoy a facial that incorporates a lot of massage and stress therapy, or do you prefer a simple skin treatment?______Do you prefer organic products?______

Treatment Info

Do you prefer a heated treatment bed? ______Are you sensitive to fragrances or essential oils? ______Do you prefer the pressure in massage mild, moderate or firm? ______You may receive a foot massage/reflexology, hand /arm, facial or scalp massage depending on your treatment. Circle any that you would rather not receive. Circle your music preference Relaxing piano, native American flutes, spiritual hymns, celtic, jazz, nature sounds or none.

Do you have any other concerns or questions not listed? ______

When was your last chemical peel or skin resurfacing treatment? ______

Are you currently using a prescription Retin A product? ______

Consent for treatment

I ______give permission for Brenda Berndt/glo facial spa & skin center to treat me today. I have disclosed any allergies, current medical conditions that I am being treated for and release Brenda Berndt/glo facial of any liabilities that may arise during my treatment. If my treatment is ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

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