Client Skincare Intake and Consent Form

bareGlo Studio

Client Intake and Consent Form
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
How did you hear about bareGlo Studio?*

Facebook/InstagramOnline SearchReferralOther
If referred, by who?
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*
If other, please explain:
Have you had a facial treatment before?*

YesNo
If yes, when was your last facial or skin treatment?

MonthDayYear
Date
Have you received any of these skin care treatments?*

Chemical PeelMicrodermabrasionDermaplaningMicroneedlingFacial UltrasoundLaser Hair RemovalLaser TreatmentsWaxingNoneOther
If you checked any of the above, please select one:

YES, within the last 7-10 daysYES, within the last monthYES, within the last 2-3 months
Have you had Botox or other injectables?*

YesNo
If yes, date of last treatment?

MonthDayYear
Date
What do you consider your skin type?*

Normal (no visible blemishes, fine pores, smooth textureOily (enlarged pores, excess oil)Acne (cystic or nodules)Dry (dull, visible lines/wrinkles, feel tight)Aging (dry, very visible deep lines/wrinkles)Combination (oily and dry patches, oily t-zone, hormonal acne)Sensitive (reactive to fragrance, often irriated)Not sure
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin)?*

YesNo
Do you have frequent breakouts?*

YesNo
What skin care products do you currently use?*

SoapCleanserTonerExfoliator or ScrubMaskMoisturizerSunscreenNoneOther
What is your daily skin care regimen? *
Do you use sunscreen?*

AlwaysOftenSometimesNever
What are your specific concerns at this time regarding your skin?*
What is your skin care goal?*
Indicate what services or areas for which you are interested in (check all that apply):

Minimize/Remove Sun Spots / Brown SpotsMelasmaWrinkle ReductionAcne TreatmentMicroneedlingRosaceaGeneral Skin CareOther
By SUBMITTING THIS FORM, you agree to the following:

I give permission to receive present and future acne treatment services, facials, waxing services, lash lift, brow lamination, enzyme peels, chemical peels, microdermabrasion, hydra dermabrasion, dermaplaning, extractions, micro needling, nano infusion, LED Light Therapy, high frequency, ultrasonic, and other electrical modalities as necessary.

I understand that it is my responsibility to inform my esthetician of any discomfort I may feel during the session so he/she may adjust accordingly.

I understand that although complications are "rare" during a service it is important to inform the servicer of any discomfort.

I understand that the service provider may take pictures for social media and/or progress monitoring.

I have read the contents of the consent form, as well as agreed to the cancellation policy terms and conditions.

I understand that I or the Esthetician may terminate the session at any time.

I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the esthetician know about any changes to these.

I, therefore, release bareGlo Studio from all liability concerning these complications that may occur by signing below.
Signature*

Clear
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bareGlo Studio