CLIENT INFORMATION & INDEMNITY FORM

PERSONAL DETAILS

First name

Last name

Birthday

Year

Month

Day

ID Number

Gender

Male

Female

Other

Phone

Home Address

MEDICAL HISTORY

Current Conditions, previous discomfort, stinging or adverse reaction?

Please indicate where applicable:

Inflammation of eyelid/eyebrow area

Yes

Skin trauma, swelling, or abrasions?

Yes

Recent operations around the eye, head or face in immediate area?

Yes

Recent tattooing, microblading, or feather touch treatments?

Yes

Previous reaction to Henna application?

Yes

Currently undergoing chemotherapy (Cancer treatment)?

Yes

Eye infections/conjunctivitis?

Yes

Recent eye surgery?

Yes

Hypersensitive skin/bruise easily?

Yes

Sunburn?

Yes

Recently had Botox or dermal fillers

Yes

Skin disorder/disease?

Yes

Currently using Roaccutane or local Accutane preparations?

Yes

Are you pregnant or suspect that you may be pregnant?

Yes

Are you allergic to any medication/food/substances?

Yes

If yes please specify

Do you currently have, or have been diagnosed with any chronic medical condition (ie diabetes, asthma, hypertension, seizures, etc)?

Yes

If yes please specify

Are you currently experiencing any health issues/symptoms we need to be aware of?

Yes

If yes please specify

AEASTHETIC HISTORY

Have you ever had any of the following treatments?

Laser Therapy

Yes

Chemical Peels

Yes

Dermal Abrasion Therapy or Microdermabrasion?

Yes

Botox

Yes

Fillers

Yes

Threads

Yes

Carboxy Therapy

Yes

Microcurrents

Yes

How do you prefer your massage pressure?

Hard

Medium

Soft

EMERGENCY CONTACT

Name

Surname

Mobile Number

DECLARATION

I hereby consent to the discussed treatments and confirm my medical history is accurate. I take full responsibility for my health and will not hold GLO SPA or its therapists liable for any complications, and have not been pressured to sign the indemnity form.

I am aware of possible risks and will contact GLO SPA within 3 days if issues arise. I confirm I am over 18, and not pregnant, but will inform GLO SPA if this changes.

For face treatments I understand the minor risks of fever blisters, acne flare-ups, or skin peeling.

I understand GLO SPA is cash-based and payment is due upon treatment completion. Group bookings require upfront payment. I accept responsibility for missed appointments and understand late arrivals may result in a shortened treatment with no reduction in treatment fees.

I opt into the GLO SPA WhatsApp Broadcast Group for updates on specials, new products, and services.

Name

Surname

Place

Date

Year

Month

Day

Signature

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