Facial Consent and Intake Form

Date

Name

First NameLast Name

Date of Birth

Date

Email

example@example.com

Phone Number

Area CodePhone Number

If you were referred to me, by who?

Are you currently under the care of a physician?

Have you experiences any of these health conditions in the past or present?

Any known allergies?

List medications/supplements you are currently taking.

Have you ever received any botox or fillers? if so, when was the last time?

What are your skin concerns?

What would you say your skin type is?

What skin care products do you use on a daily basis?

Do you experience routine breakouts or acne?

Have you been diagnosed with eczema, psoriasis or rosacea?

Have you received any of these facial hair removal services in the last 7 days?

Do you currently use:

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain:

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

Do you?

Are you taking birth control?

Are you pregnant or breast-feeding?

I acknowledge that I must adhere to Glamberly Beauty’s policies. I understand that cancellations must be done with at least 24 hours notice. Failure to do so will result in a fee of 30% of the total service cost. I acknowledge that ANY no show will result in a fee of 100% of the total service cost and I will no longer be able to book with Glamberly Beauty. I understand that after 15 minutes of tardiness my appointment may be subject to cancellation.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm for atleast 2 days after my treatment. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment. I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments with Glamberly Beauty. I release Amberly Locastro and Glamberly Beauty of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature

Glamberly Beauty

Your Medical History

Your Skin

Female Clients