New Client Consultation Form

Full Name (or name of minor getting service)*

First NameLast Name

Name of parent (if minor receiving service)

First NameLast Name

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Emergency Contact (Please include phone #)*

E-mail*

How did you hear about GLO Beauty Bar?*

If Referral or Other, please specify or name:

Is there a smell you don't like*

There are no smells that bother meOther

Should provider wear gloves?*

Yes, GlovesNo GlovesIt does not matter to me (gloves)

Extractions?*

Yes extractionsNo extractions

Do you like steam during your facial?*

Yes, SteamNo SteamNot Sure

Included Massage:*

Yes, MassagePlease skip this touch portion. (In this instance, you would lay and listen to music while I update your chart).

Included Scalp Massage:*

Yes, ScalpNo ScalpNot sure yet...Ask me in session

Music preference*

Special requests to make you more comfortable?

When was your last facial?*

What are the expectations of your visit today?*

I want to start a skincare regimine, please show me productsRelaxTackle Issues/ConcernsOther

How would you describe your skin type?*

Which skin type best describes you? (Do the best you can to answer)*

What are your skin care challenges?*

Anything else we should know about your skin?

Have you used Vitamin A Retinoids like Tretinoin, Retinaldyhyde, Retinol, Differin, Retinal or Bakuchiol.*

NoYes, within the last 5 daysYes, but not in the last 5 days

Have you used any acids*

NoYes, within the last 3 daysYes, but NOT in the last 3 days

Have you used a peel, scrub, laser, microdermabrasion, or dermaplane?*

NoYes, within the last 30 daysYes, but NOT in the last 30 days

If yes, please specify treatment.

Plastic Surgery, Botox, Juvederm, or other fillers IN THE LAST 2 WEEKS*

Yes, fillerYes, botox or disportNo

If yes, please specify placement of botox/filler

Pregnant? If so, Please specify weeks

If possible upload a photo. This is helpful to assess, but not required.

Browse Files

Do you?*

Any known allergies?*

Other Allergies?

Health History (Face)*

Health History (Body)

Contraindications to treatment. Please check all that apply currently. If issues require resceduling we will contact ASAP*

These conditions MAY need doctor's approval for Massage. Please check all that apply:

If we missed anything, let us know here:

1) I have revealed all physical limitation(s), musculoskeletal issues, health conditions, medications or allergies that may affect treatment but understand that complications or allergies (though rare) can still occur during or after session. In this event, I will contact GLO and seek medical attention immediately if necessary.

2) I understand that in some treatments I may experience some degree of discomfort, bruising, increased surface blood vessels, small knicks or small skin abrasions.

3) I undertand the outcome of treatment cannot be guaranteed and for some treatments, a series may be necessary. Results are highly dependent on age, sun exposure, health, lifestyle, genetic traits, skin condition, and a willingness to follow recommended protocols and home care.

4) I have been informed of the possible risks and complications, pre and post care, recommendations, contraindications, expected healing process and have chosen to proceed with the treatment after careful consideration of the known and unknown risks, complications, and limitations. (Visit our website for this info: www.myglobeautybar.com)

5) I understand that any illicit or sexually suggestive remarks/requests, touching (either self or therapist) or sexual advances will result in the immediate termination of the service and full payment will be charged. If necessary, authorities will be notified. Zero tolerance spa.

6) I understand that I am able to ask questions during my facial/massage. The provider is Licensed by the Medical Board of Ohio, and the Board of Cosmetology and will be happy to keep me well informed and comfortable.

7) If at any point during the facial/massage I am uncomfortable or uneasy with the techniques being administered and/or I am experience pain or discomfort, I understand it is my responsibility to IMMEDIATELY inform the Therapist so that the service can be terminated or the pressure / techniques can be adjusted to a level of comfort.

8) I understand that this service is not a substitute for a medical examination, diagnosis or treatment.

9) I understand that before and after photo’s will be taken for medical records. These will not be displayed publicly unless you agreed to the media consent below.

10) I have reviewed and agree to GLO Beauty policies on lateness, cancellations, no show, rescheduling and sickness policies that were provided at booking.

11) In order to provide you with the best possible care, we occasionally send emails and/or SMS/MMS mobile messages to our clients. Depending upon your phone coverage, text fees may apply. You may opt out of both of these services in the future.

12) I give permission to Victoria Buck of GLO Beauty Bar, to provide the service I have booked and will hold her harmless from any liability that may result from this treatment. I understand she will take every precaution to minimize or eliminate negative reactions.

I understand and agree to these policies + consents

Yes, I agree

If you agree to the media consent, you give GLO Beauty Bar, LLC permission to acquire and use your photo, video, and/or voice. You agree that GLO Beauty Bar, LLC has complete ownership of said pictures, videos, etc., and may edit, alter, copy, exhibit, publish, or distribute them for advertising, educational, and marketing needs. These uses include, but are not limited to websites, social media, before and after photos, publications, advertisements, promotional, educational materials, or for any other lawful purpose in any medium now known or later developed.

You acknowledge that you will not receive any compensation, etc. for the use of such pictures, etc., and hereby release GLO Beauty Bar, LLC from any claims, which arise out of such use. You understand that GLO Beauty Bar, LLC cannot control the unauthorized use of images, video, or audio by persons not associated with GLO Beauty Bar, LLC once material has been published. You hereby forever waive any right to inspect or approve any publication by GLO Beauty Bar.

Choose one

I understand and agree to GLO Beauty Bar, LLC's Media Consent FormPlease do not share or take photos of me

If you would like to be tagged please enter your social media name

By signing below, I acknowledge that I have read and understood the above information, answered truthfully, and given an accurate account of my medical history.

I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have had sufficient opportunity for questions or concerns regarding my treatment or suggested home product/pre/post-treatment care. In the event that I may have additional questions or concerns, I will consult my esthetician immediately.

This Facial/Massage consent form is valid for 1 year. I agree to alert the staff if there are any future changes to my medical history.

Signature*

Facial & Massage Consultation & Consents

Tell Us About Your Skin

Health History

GLO Beauty Bar, LLC CONSENTS

MEDIA CONSENT

CLIENT SIGNATURE