New Client Intake Form Name * First Name Last Name Gender * Male Female Date of Birth * MM DD YYYY Cell Phone * (###) ### #### Email * Tell us what your skin goals or concerns are! The more we know the better! * Do you have any of the following conditions? If yes, please select them: * Cancer Pacemaker or Defibrillator Claustrophobia Thyroid Disorder Epilepsy or Seizures HIV/AIDS Psoriasis Eczema Lupus Blood Clot Disorder Menopause Metal Implants Diabetes Heart Disease Hormonal Imbalance Blush Easily Hepatitis A/B/C Rosacea Immune Disorder Keloid Scarring Skin Disease Other None Skin Type * (It's okay if you are not sure - let us know what you think you are) Normal Oily Dry Combination Other What's your skin care routine? Please enter the products you are currently using for each category. Cleanser * Toner * Exfoliator * Serums * Moisturizer * SPF * Does your job or lifestyle require that you work/play outdoors? * Yes No Have you ever had facials, chemical peels, microdermabrasion, or any resurfacing treatments? * Yes No Are you using Retin-a? * Yes No Are you using Benzoyl Peroxide? * Yes No Are you pregnant? * Yes No Do you take any medications? If so, what? * Are you taking any birth control? * Yes No Are you taking any antibiotics? * Yes No Are you taking Accutane? * Yes No Are you breastfeeding? * Yes No Are you Claustrophobic? * Yes No Do you have any alleriges? * Yes No If you do have allergies, list them here. How did you hear about us? * Terms & Conditions I have read and completed this questionnaire truthfully. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments I receive are voluntary aand I relase the company and/or skin care professional from liability. GLO Aesthetics charges a 50% cancellation fee for any no-shows or cancellations if less than 24 hrs of the scheduled appointment. This also goes for clients that are 10 minutes late of scheduled appointment time. Should your card decline, you will be required to pay a cancellation fee day of cancel. Should you not pay day of you will be required to pay at next booking appointment PLUS pay up front for services. There is no exception. All treatments, services and products are non- refundable. * I understand and agree to the terms and conditions. Signature * Type in First and Last name to complete signature. Date Signed * MM DD YYYY Thank you!
