New Client Consultation Form

Glow by Aika

NEW CLIENT CONSULTATION FORM
Thanks for trusting me with your facial skin care. I can't wait to work with you!

At Glow by Aika, we aim to provide a holistic approach to your facials.

If you have any questions, please feel free to DM me @glowbyaika.co or email at roqueaika@gmail.com
Date*

MonthDayYear
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
What city are you from?*
How did you hear about me?*
Instagram handle*
Type N/A if not applicable
If Referral, please list name
If Other, please let me know
Your Skin
What are your skin care goals? *
Wrinkles / Fine LinesHyperpigmentation / Sun DamageBreakout / AcneAcne ScarringRedness / RosaceaAgingUneven Skin ToneSensitivityBroken CapillariesDull/Dry SkinFlaky Skin/ DehydratedPuffy/Dark UndereyesOther
Please feel free to go into more detail
YesNo
If Yes, when and what kind?
Do you use skin care products?*
If you use any skin care products, please provide brands below if known. If not applicable, please type N/A.
Face Scrub/ Exfoliants
Masks
Cleanser/ Face Wash
Toner
Serum/ Face Oil
Eye Product
Moisturizer
Sunscreen & SPF
Other
Do you/have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivitives?*
Please specify which product or type, if you answered 'Yes, currently using' to above.
WaxingSugaringThreadingElectrolysis / LaserDepliatory CreamShavingNone
If checked, please note last time.
Have you ever received chemical peels, laser services, or microdermabrasion treatments? *
YesNo
Your Health
YesNo
YesNo
AspirinTree NutsLatexDairyFruitsVegetablesShellfishIodineFragrances / Essential OilsOtherNone
If Other, please specify
YesNo
If yes, please specify what and date last used
PLEASE NOTE: Glow by Aika prides itself on achieving great integrity and professionalism. All information provided above will be held in strict confidentiality. Information above is necessary to ensure quality and safety of all clients.
COVID-19 WAIVER
I am not experiencing any symptoms of illness such as a cough, shortness of breath or difficulty breathing, fever, chills, muscle pain, headache sore throat, nausea, vomiting, diarrhea, or new loss of taste or smell.I have not travelled outside of Canada within the last 14 days.I do not believe I have been exposed to someone with a suspected and/or confirmed case of the COVID-19 Virus.I am following all recommended guidelines as much as possible and limiting my exposure to COVID-19 virus.If I am not feeling well; I will reschedule my appointment 24 hours prior to my appointment time.I have been Covid-19 double vaccinated
Post Facial Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours for specialized services. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). Apply a broad spectrum sunscreen of SPF 30, especially for specialized services, which could make your skin more sensitive initially. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional or doctor before resuming topical treatments. Enzyme peels, active ingredients, extraction, and microdermabrasion can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results.*

I have read the post care instructions and agree to adhere to them.
Reservation & Cancellation Policy for all current and future appointments: non-refundable deposit, signed general consent form, and signed booking form with covid-19 waiver are required for all appointments. Please do not forget to confirm your appointment when you receive your reminder. In the event of cancellations received less than 24 hours prior to appointment or no shows, deposit will be non-refundable. No Shows will not be provided services in the future.*

I understand the reservation and cancellation policies at Glow by Aika.
I understand, have read and completed this questionnaire 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 treatments received. The treatments I receive here are voluntary and I release this skin care professional from liability and assume full responsibility thereof.*

Yes
Signature*

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Glow by Aika

Your Skin

Your Health

COVID-19 WAIVER