Client Consultation Form
Name ________________________
Zip code __________
Address ____________________________
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? ________
or essential oils? ________
or firm? __________
Are you sensitive to fragrances
Do you prefer the pressure in massage mild, moderate
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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