New Client Consultation Form

New Client Intake Form I GLO Beauty Bar, LLC

*Form is to be completed at least 48 hrs prior to first appointment
Full Name or name of minor getting service*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Emergency Contact (Please include phone #)*
E-mail*
How did you hear about GLO Beauty Bar?*

GoogleFriend or FamilyOnline SearchInstagramFacebookMailer or FlyerOther
If Referral or Other, please specify or name:
Is there a smell you cannot handle, for example minty, floral etc.?*

There are no smells that bother me
Do you prefer I wear gloves for massage portion*

Yes, GlovesI prefer no GlovesIt does not matter to me (gloves)
Do you prefer that your esthetician wears a mask*

YesNot necessary
Do you want extractions or prefer to skip*

YesSkip
Do you like to be under the steamer*

YesNoNot sure
Are you claustrophobic*

YesNo
Your facial probably comes with massage on one or more of these areas: face, arms, hand, décolletage, neck*

Heck yeah I want it!Please skip this touch portion. (In this instance, you would lay and listen to music while I update your chart).
Do you have any special requests to make you more comfortable? ex: need head elevated, use bolster to support back etc.?*
Tell Us About Your Skin
When was your last facial?*
What are the expectations of your visit today?*

Product Recommendations, please show me ideasRelaxation onlyRelax and tackle Issues/Concerns
How would you describe your skin type?*

DryOilyNormalCombinationSensitivityAcne Prone
Which skin type best describes you? (Do the best you can to answer)*
What are your skin care challenges?*

Wrinkles / Fine LinesHyperpigmentation / Sun DamageMelasmaAcneAcne ScarringOily SkinRednessAgingSensitivityDull ComplexionBumps or Rough TextureFacial VeinsLarge PoresBroken Blood VesselsBlackheadsNodules & CystsFacial HairFrecklesDry SkinDehydrate skinRosaceaPsoriasisEczemaNone of the aboveUndereye issuesClogged Pores & Blackheads
Is there anything else that is important for us to know about your skin? Explain:
Adding skin care products you use here helps us keep your skin safe!
Do you/have you used Vitamin A Retinoids like Tretinoin, Retinaldyhyde, Retinol, Differin or Retinal.*

NoYes, within the last 5 daysYes, but not in the last 5 days
Do you/have you used any acids such as Glycolic Acid, Lactic Acid, Mandelic Acid*

NoYes, within the last 3 daysYes, but not in the last 3 days
Have you used a chemical peel, laser services, microdermabrasion, ordermaplane treatments?*

NoYes, within the last 30 daysYes, but not in the last 30 days
If yes, please specify treatment.
Have you received any Plastic Surgery, Botox, Juvederm, or other dermal fillers IN THE LAST 2 WEEKS*

Yes, fillerYes, botox or disportNo
If possible upload a photo. This is helpful to assess, but not required.

Browse Files

Cancelof
Health History

*Very important to determine eligibility of a service
Check any that currently Apply*

Hormone ImbalanceCancer / Systemic DiseaseHigh Blood PressureDiabetesHeart problemArthritisAuto-Immune DisordersAsthmaEpilepsy / Seizure DisorderFever BlistersFrequent Cold SoresHIV/AIDSLupusHepatitisHeadaches / MigrainesAcneKeloidFibromyalgiaACTIVE Skin CancerShinglesUndergoing hormone replacementPregnantBreast feedingSunburnt or windburnClaustrophobicNone of the Above
Do you?*

Wear contact lensesHave a pacemakerHave metal implantsHave ear piercingsHave body piercingsWear Eyelash ExtensionsNo, not Applicable
Any known allergies?*

AspirinTree NutsLatexDairyFruits (specify below)VegetablesShellfishIodineFragrances / Essential OilsNickelSulphurNo AllergiesSulphahoney, Beeswax or RosinLicoriceCBD/HempEggsAlgaeseaweed
If Other, please specify
CLIENT SIGNATURE
By electronic signature below I affirm I understand the information I have given is to aid the esthetician and is not a substitute for medical care. I agree that I have answered all of the questions truthfully and accurately. I also agree that it is my responsibility to notify GLO Beauty Bar, LLC if any of this information changes or needs to be updated.
Signature*

Clear
Should be Empty:

Now create your own Jotform - It's free!Create your own Jotform

New Client Intake Form I GLO Beauty Bar, LLC

Tell Us About Your Skin

Health History

CLIENT SIGNATURE