Client Consultation Form

Name ________________________ Address ____________________________Zip code __________ email_________________ Phone ________________Would you like to have our specials e-mailed to you? _________How did you hear about glo? ____________________________ Who can we thank?______________What is your birthday? ___________________

Health Info.

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc……Please list. _______________________________________________________

Are you currently being treated by a physician for any conditions? _____________Please list any medications that you are taking. ____________________________ ______________________________. Are you pregnant or nursing? _______ What trimester? _____Please list any surgeries in the last year. __________________________________Do you have any metal implants or a pacemaker? ___________________________Do you use a tanning bed? ____________ Do you use a sunscreen daily? ________What SPF? __________Ladies, please list first day of last menstrual period. ________________How many hours do you sleep at night? _____ Are you claustrophobic? _________

Nutrition/Lifestyle

How many 8 oz glasses of water do you drink daily? __________ How many cups of coffee/other caffine? __________ Do you exercise? ________ How often? ___________ On a scale of 1-10, how would you rate your stress level today? ___Do you take any vitamins or supplements? Please List. _____________________________________________________________.

Skin Info.

Please put an X next to conditions that you are concerned with.Dark spots on your skin or uneven skin tone, face or body __ Acne breakouts or congestion ___ wrinkles or fine lines___ Facial hair __ Body hair ___Thin or misshaped brows ___ Redness or Rosaccea __ Lack of Skin tone (firmness) ____ Stress _____ Cellulite _____ Rough skin or Keratosis Pilaris ____ Dry skin ______ Sensitive skin ___ Dullness _____ Fading of lip color _____ Thinning lashes ___Dark circles under eyes _____ Puffiness under eyes _____ Tired, droopy eyes ___

What would you like to accomplish with your treatment today? ____________________________________________________________________________________

Do you currently cleanse your skin morning and night? _______ What product do you use? ________ Please also list any toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you enjoy spending time on your skin routine, or do you prefer a very simplified approach?____________________ Do you burn easily in the sun? ____________Do you get an oily shine throughout the day?_________ Would you consider your skin oily, dry or normal or sensitive? ___________ Do you enjoy a facial that incorporates a lot of massage and stress therapy, or do you prefer a simple skin treatment?___________________ Do you prefer organic products?___________

Treatment Info

Do you prefer a heated treatment bed? ________ Are you sensitive to fragrances or essential oils? ________ Do you prefer the pressure in massage mild, moderate or firm? __________ You may receive a foot massage/reflexology, hand /arm, facial or scalp massage depending on your treatment. Circle any that you would rather not receive. Circle your music preference Relaxing piano, native American flutes, spiritual hymns, celtic, jazz, nature sounds or none.

Do you have any other concerns or questions not listed? ________________________When was your last chemical peel or skin resurfacing treatment? _______

Are you currently using a prescription Retin A product? __________

Consent for treatment

I ________________ give permission for Brenda Berndt/glo facial spa & skin center to treat me today. I have disclosed any allergies, current medical conditions that I am being treated for and release Brenda Berndt/glo facial of any liabilities that may arise during my treatment. If my treatment is ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

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