The Perfect Glo- Intake Form

FACIAL
CLIENT INTAKE FORM
the perfect glo
APPOINTMENT DATE

MonthDayYear
Date
APPOINTMENT TIME
NAME
AGE
GENDER
ADDRESS
ZIP
STATE
EMAIL
example@example.com
PHONE:
How did you hear about us?

Other
What are your long term skin goals?
What are your areas of concern?
What are your goals from today's treatment?
Have you ever had professional skin care treatments previously?
If yes. please explain
Do you wear contact lenses?
What skin care products do you use presently?
Exposure to sun?
MEDICAL INFORMATION:
Are you presently using (or used in the past) Azlex, Differin. Renova, Retin-A. Tazarac. Glycolic or Alpha Hydroxy Acids?
If yes, when and for how long?
Are you now using or have you ever used Accutane?
Please list any allergies you have: (including cosmetics or Ingredients)
Please list any allergies you have
List all medications you are taking: (including OTC drugs, vitamins etc
List all medications you are taking
Do you smoke?
Have you ever had any of these conditions ? If NONE apply. please tick
Asthma
Any other
Ihave read the above information and have given an accurate account of the questions. If have any concerns. I will address these with my esthetician before the service. I understand that the services offered are not a substitute for medical care and any information provided by the therapist is for educational purposes only and not diagnostically prescriptive in nature. I give permission to my esthetician to perform the facial service and will not hold the esthetician nor [The Perfect Glo] accountable for any liability that may result from this treatment I understand that theinformation herein is to aid the therapist in giving better service and is completely confidential.
Client Name
Client Signature
Date

MonthDayYear
Date
Esthetician Name
Esthetician Signature
Date

MonthDayYear
Date
PHOTO/VIDEO RELEASE FORM
FACIAL
I, _____________________________ hereby grant and authorize [The Perfect Glo] the right to take. edit, alter, copy. exhibit. publish. distribute and make use of any and all pictures. video. and/ or audio taken of me to be used in and/ or for any lawful promotional materials including. but not limited to. newsletters. layers. posters. brochures. advertisements. press kits. websites. social media sites. and other print or digital communications without payment or any other consideration

This authorization extends to all languages. media. formats, and markets now known and

Iwill be consulted about the use of the photograph and/ or video recording for any

purpose other than those listed below:

Printed and/ or digital advertisements Educational presentations or courses Informational presentations

Online educational courses Educational videos

There is no time limit on the validity of this release. nor is there any geographic limitation on where these materials may be distributed

By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Name

First Name Last Name
Full Name
Address
Email
example@example.com
Phone
Format: (000) 000-0000.
Signature
Date

MonthDayYear
Date
Should be Empty:

FACIAL

CLIENT INTAKE FORM

the perfect glo

PHONE:

MEDICAL INFORMATION:

PHOTO/VIDEO RELEASE FORM

FACIAL