New Client Consultation Form

Full Name (Or name of minor getting service)*

First NameLast Name

Name of parent (If minor receiving massage. Min. age is 15. 15-17 must have parent in room)

First NameLast Name

Date of Birth:*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Emergency Contact (Please include phone #)*

E-mail*

How did you hear about GLO Beauty Bar?*

If Referral or Other, please specify or name:

Do you want the therapist to wear gloves*

Yes GlovesNo Gloves

Scalp Massage is included, Would you like it*

Yes ScalpNo ScalpNot sure yet...Ask me in session

There is no inappropriate touching involved at GLO however, some OVER the sheet glute work MAY be done at request. Involves Gentle compressions*

Yes Glute WorkNo Glute Work

Please specify if there are areas you DISLIKE being massaged so we can avoid *

Do you have any special requests to make you more comfortable? ex: need head elevated, use bolster to support back etc.?*

Music selection for massage*

When was your last Massage + what type was it? (Relaxation, Swedish, deep tissue, Stone etc)*

How would you describe your health*

PoorFairGoodExcellent

Do you have any allergies or hypersensitivities?*

Are you feeling Pain? Please elaborate where and rate on a scale of 1-10*

List any major accidents or surgeries (including dates)*

Please list current medications*

Are you pregnant? (How many weeks. First trimester should get doctors permission)*

Do you have impaired vision/hearing/Mobility?*

Contraindications. Massage CANNOT be performed in these situations. Please check all that apply*

Other Health Situations, Please check all that apply. (Can massage with minor adjustments to technique)

May need Doctor's approval, Please check all that apply.

Is there anything else that is important for us to know:

1) I understand that the Spa massage w/LED Light Therapy I am consenting to is Swedish or Hot Stone. It is typically light to firm pressure, but can intensify if needed/appropriate.

2) I understand that any illicit or sexually suggestive remarks/requests, touching (either self or therapist) or sexual advances will result in the immediate termination of the massage and full payment will be charged. If necessary, authorities will be notified. Zero tolerance spa.

3) I will notify my esthetician of any physical limitation(s), musculoskeletal system issue, allergies or health concerns I have before the massage.

4) I understand that I have read all of the contraindications listed here and on our website, and agree I have notified on this form if any apply.

5) I understand that although complications are rare, sometimes they occur. In the event of a complications or allergy, please contact GLO and seek medical treatment if necessary.

6) I understand that I can provide feedback as to my personal preferences in regards to pressure and discuss painful or sensitive areas that I would not want to be massaged.

7) I understand that I am able to ask questions during my massage. The Massage Therapist is Licensed by. the Medical Board of Ohio and will be happy to keep me well informed and comfortable.

8) I understand that a massage is not a substitute for a medical examination, diagnosis or treatment.

9) If at any point during the massage I am uncomfortable or uneasy with the techniques being administered and/or I am experience pain or discomfort, I understand it is my responsibility to IMMEDIATELY inform the Therapist so that the service can be terminated or the pressure / techniques can be adjusted to a level of comfort.

10) I have been informed of the possible risks and complications, pre and post care, recommendations, contraindications, expected sequence of the healing process and have chosen to proceed with the session after careful consideration of the possibility of both known and unknown risks, complications, and limitations.

11) I understand that a client headshot will be taken for medical records. These will not be displayed publicly, unless authorized.

12) I reviewed and agree to GLO Beauty policies on lateness, cancellations, no show, rescheduling and sickness which were provided at booking.

13) In order to provide you with the best possible care, we occasionally send emails and/or SMS/MMS mobile messages from 614-880-8222/myglobeautybar@gmail.com or from our booking app to our clients. Depending upon your phone coverage, text fees may apply. I agree to allow GLO to send these messages/texts and understand there is an option to opt out of both of these services in the future. Please note you may not receive important appt info if you opt out.

14) I give permission to Victoria Buck, LMT of GLO Beauty Bar, to perform a Massage (and any add on services requested) and will hold her harmless from any liability that may result from this treatment. I understand he/she will take every precaution to minimize or eliminate negative reactions.

I understand and agree to these policies + consents

Yes, I agree

Choose one

I understand and agree to GLO Beauty Bar, LLC's Media Consent FormPlease do not share or take photos of me

If you would like to be tagged please enter your social media name

By signing below, I acknowledge that I have read and understood the above information, answered truthfully, and given an accurate account of my medical history. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have had sufficient opportunity for questions or concerns regarding my treatment/massage or suggested home product/pre/post-treatment care. In the event that I may have additional questions or concerns, I will consult my Therapist immediately. This consent form is valid for all future massage treatments. I agree to alert the staff if there are any future changes to my medical history.

Signature*

Massage Consult & Consents

Tell Us About Yourself

Health History

GLO Beauty Bar, LLC CONSENTS

CLIENT SIGNATURE