Client Profile & Intake Form

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Glam Spa LLC - Esthetics & Body

www.glamspadc.com

Please complete form below prior to your appointment. Thank you so much!

Name *

Date of Birth *

YYYY

Email Address *

Phone Number *

Have you or any one in your home been exposed to or had COVID-19 within 14 days? Please wear mask at time of appointment. *

Yes

Which services will you be receiving? Check all that apply. (ONLY COMPLETE QUESTIONS FOR SERVICES YOU WILL BE RECEIVING, THANK YOU SO MUCH) *

Facial or Skincare Treatment

Waxing ( Hair Removal)

Yoni Steam Session

Non-Surgical Treatment/Body Sculpting

Required

This section is required for clients receiving any FACIAL, VAJACIAL OR BRIGHTENING TREATMENT, ----------------FACIAL OR SKINCARE TREATMENT: Check all that apply. Please leave blank if it does not apply.

Do you have skin allergies?

Do you suffer from sinus issues?

Do you have sensitive skin?

Do you have oily skin?

Do you have dry skin?

Do you experience skin breakouts?

Have you ever had a bad reaction to a skin care product?

Within the last year, have you been under the care of a dermatologist or other physician's care?

Do you have special skin problems or concerns?

Do you currently use Accutane, Retin A, Renova, Adapalene or any other prescription skin care products?

Are you currently using any products with the following ingredients Glycolic Acid, Lactic Acid, Exfoliating Scrubs, Hydroxy Acids, Vitamin A Derivatives?

Have you ever had chemical peels, microdermabrasion or any resurfacing treatments?

Do you drink water, eat fruit and vegetables daily?

What are your skin care goals? ---------Required for all clients receiving a FACIAL, VAJACIAL OR SKINCARE TREATMENT.

ESTHETICS/SKINCARE CONSENT: I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in the above information. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history.

This section is required for clients receiving any WAXING (HAIR REMOVAL SERVICE), ----------------WAXING (HAIR REMOVAL SERVICE) : Check all that apply. Please leave blank if it does not apply.

Is this your first wax session?

Do you receive waxing services often?

Do you get ingrown hairs?

Do you have skin breakouts or sensitive skin?

I understand that some side effects of waxing include redness, swelling and pimples that only last up to 72 hours.

Are you allergy to any skin care products or certain wax products? Please share this with your technician prior to starting wax session.

Are you taking Accutane, Retinoids, AHAs/BHAs or Glycolic Acid?

Do you have dry skin?

Do you have diabetes or phlebitis?

BRAZILIAN/BIKINI WAX: I agree that I will notify my technician if I am currently on my cycle. Please wear a tampon.

I agree that I do not have any active open skin lesions or active outbreak.

I agree to adhere to all post safety advice: No tanning beds, skin peels up to 72 hours post wax.

I am over 18 years old.

WAXING Consent: I, _______________________ (print name) give consent to the licensed professional to perform waxing services on me.

This section is required for clients receiving a YONI STEAM, ----------------YONI STEAM : Check all that apply. Please leave blank if it does not apply.

Are you currently on your menstrual cycle (period)?

Have you any vaginal procedures within the last 3 months?

Are you currently trying to get pregnant?

Are you currently receiving any fertility treatments?

Do you have a irregular cycle?

Are you currently on birth control?

Are you allergic to any herbs?

You agree to remove all vaginal piercings during the yoni steam.

You agree that you are not pregnant, withholding any medical contradictions and will not hold Glam Spa LLC or any technicians responsible for injury.

You understand that there is no yoni steaming allowed while pregnant or on period (menstrual cycle).

YONI STEAM CLIENTS ONLY: Please list any herbs you may be allergic to:

This section is required for clients receiving any NON-SURGICAL OR BODY SCULPTING TREATMENT, ----------------NON SURGICAL/BODY SCULPTING Treatment: Check all that apply. Please leave blank if it does not apply.

Are you sensitive to light or sun rays?

Do you have cardiovascular or vascular conditions?

Are you currently pregnant?

Do you have high or low blood pressure?

Do you have lymphatic or thyroid conditions?

Do you have liver or kidney conditions?

Have you been diagnosed with any forms of cancer? Are you currently undergoing treatments?

Do you have diabetes?

Are you currently taking any medications?

Do you have a pacemaker?

Do you have any blood clotting conditions?

Do you have any chronic health conditions?

Do you drink water, eat fruit and vegetables daily?

Do you workout weekly?

Do you have a waist trainer?

What areas of your body are you looking to treat? Please list below: *(NON SURGICAL/BODY SCULPTING CLIENTS)*

What are your body goals?

NON SURGICAL/BODY SCULPTING CONSENT: I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I understand that non-invasive surgery procedures do not rid the body of visceral fat.I hereby release and forever discharge the Clinic, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, the Clinic for any liabilities, damages, injuries whether seen or unforeseen. I understand that any procedure under the Clinic does not constitute medical treatment or cure to any illness. By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence. (PRINT NAME BELOW):

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