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Forms

MIRAGE Salon & MedSpa

Glo Skin Client Information Form

Client Information

Tell us about your skin:

What is your skin type?
What are your skin concerns?
Have you ever experienced any of the following?
Do you consider your skin sensitive (including: redness, stinging, itching, dryness)?
Yes
No
When exposed to the sun do you:

HOMECARE

What skincare products are you currently using at home?
Do you sunbathe or participate in regular outdoor activities?
Yes
No
Have you had any direct sun exposure in the last 10 days?
Yes
No
Do you tan or use a tanning booth?
Yes
No
Do any of your products contain any of the following?
Are you currently using any of the following prescription products?
Have you ever received a professional skincare treatment before?
Yes
No

Tell us about your wellness

Please check any of the following that are applicable:
Have you ever had a reaction or are allergic to any of the following:
Within the last year have you been under the care of or had:
In the last 14 days have you had any of the following?
Are you currently taking any medications, nutritional supplements, etc.?
Yes
No
Female clients only, please check any of the following that are applicable:

Consent

I have acknowledged that all the information provided by me is true and correct to the best of my knowledge. I understand that some skin conditions may require more than one treatment and homecare products to achieve the result desired. Results cannot be guaranteed due to individual skin type(s) and condition(s). I understand I need to sign this waiver prior to every treatment provided, with ANY changes pertaining to the above information.

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