Facial Agreement Form Name * First Name Last Name Today's Date: * MM DD YYYY Email * Phone Number * Date of Birth * MM DD YYYY Your Skin What are your skin goals? * What are your skincare challenges? * Wrinkles / Fine Lines Hyperpigmentation / Sun Damage Acne / Acne Scarring Redness / Rosacea Aging Melasma Sensitivity Other Have you ever had a facial or skin treatment before? * Yes No What skin care products do you currently use? * Cleanser / Face Wash Bar Soap Face Scrub / Exfoliants Toner Serums Moisturizer Sunscreen Eye Product(s) Lip Product(s) Do you or have you used Retin-A, Renova, Adapalene, Accutane, Differen, Glycolic Acid, Lactic Acid, Mandelic Acid, Retinol, or other Vitamin A derivatives? * Yes, currently using Yes, but not within the last 30 days Yes, but not within the last 6 months No Not sure Have you received any of these hair removal services in the last 30 days? * Waxing Sugaring Threading Electrolysis / Laser Depilatory Cream (i.e Nair) Shaving None Have you ever received chemical peels, laser services, or microdermabrasion treatments? * Yes, within the last month Yes, within the last 2-3 months No Have you received any Botox, Juvederm, or other dermal fillers in the last two weeks? * Yes No Your Health Have you experienced any of these health conditions in the past or present? * Hormone Imbalance Cancer / Systemic Disease High Blood Pressure Diabetes Heart Problems Arthritis Auto-Immune Disorders Asthma Epilepsy / Seizure Disorder Fever Blisters Herpes Frequent Cold Sores HIV / AIDS Lupus Depression / Anxiety Hepatitis Headaches / Migraines Other None Do you....? * Wear contact lenses Have a pacemaker Have any metal implants Have body piercings No, not applicable Do you have any of the following allergies? * Aspirin Tree Nuts Latex Dairy Fruits Vegetables Shellfish Iodine Fragrances / Essential Oils Other None Are you currently taking any prescription medication? * Are you a smoker? * Yes No Occasionally Do you drink more than 4 caffeinated beverages a day? * (tea, coffee, soda, energy drinks, etc) Yes No Have you ever experienced claustrophobia? * Yes No Please rate your stress level * Low Medium High Females Clients Are you taking birth control? * Yes No N/A Are you pregnant or trying to become pregnant? * Yes No Recently had a baby and am breastfeeding N/A Any menopause issues? * Yes No N/A Are you undergoing any hormone replacement therapy? * Yes No Male Clients What is your current shaving system? * Razor / Wet Shave Electric N/A Do you experience irritation from shaving? * Yes No N/A Special Treatments Are you receiving any of the following Special Treatments? * Microdermabrasion Chemical Peel Dermaplaning N/A Do you understand and agree to all of our policies? * Yes No Post Facial Care Instructions: Aerobic exercise and/or vigorous physical activity should be avoided for 48 hours. Direct sunlight exposure is to be avoided immediately following the treatment (including any strong UV light exposure and/or tanning beds). If some sun exposure cannot be avoided first apply a broad spectrum sunscreen of SPF 30. Sunscreen (with a minimum SPF 15) should become part of your daily skin care regimen as skin can potentially become more sensitized to the sun as a result of this treatment. Unless otherwise specified, in the evening following your treatment, cleanse your skin with a mild cleanser and water followed by a non-active moisturizer. Do not apply additional exfoliating ingredients/products the day of your service as over-exfoliation can result in irritation or further sensitivity. Consult your skin care professional before resuming topical treatments. Microdermabrasion or chemical peels can result in skin flushing/redness or slight skin flaking or sensitivity for up to 48-72 hours post treatment. DO NOT peel, pick, rub, or scratch your skin at any time, whatsoever. This can potentially cause damage or compromise your results. * I have read the post care instructions and agree to adhere to them. Digital Signature * Please type your full name below. By typing and submitting this form, this serves as a Digital Signature and verifies that you fully agree to our policies for our services. Signing this document confirms that you understand and agree to all terms and statements on this form. This digital signature holds the same authority as a handwritten one. Signing and agreeing to this form makes this form valid for all future appointments and services you receive by GLO Aesthetics. Thank you! Thank you!
