A flutter of soft teal butterflies — Glowtique's emblem of transformation

Before Your Visit

Client History Form

Thank you for trusting Glowtique with your treatment. Our number one aim is to ensure you receive the safest, most gentle and effective solution tailored to you. Please complete the following form so that we can tailor the best solution for you.

Personal details

First name * Last name * Phone * Email address * Street address * Suburb * State * Postcode * Date of birth * Gender *

Where did you hear about us?

Please be specific.

Internet Referral Advertisement Others

Others (please specify):

I am interested in:

Please select all that apply.

Others (please specify):

Sunscreen

Do you use sunscreen? If yes, what SPF?

Emergency contact

Name * Emergency contact best number * Emergency contact relationship *

Skin condition

Tell us about your skin Choose the skin condition that best describes you:

Medical, skin and contra-indicative conditions

We need to ask these questions to ensure your treatment is safe and effective.

Medical conditions

Please select all medical conditions that apply:

Other medical conditions (please describe) Are you currently being treated for any conditions not listed? If yes, please specify.

Allergies

Please select if you experience any allergies:

Other allergy (please describe)

Medications or supplements

Please select if you are currently taking any of these medications or supplements:

Other medication including herbal preparations, medical patches, ASA, etc (please describe)

Previous treatments on area

Please select if you have had any of the following treatments over the area we will be working on today:

Other procedures in the past two weeks (please describe)

Have you ever used (or are currently using) Retin A or glycolic acid? If yes, please specify.

Have you ever used (or are currently using) Accutane? If yes, please specify.

Have you ever had a chemical peel? If yes, please specify.

Have you had any laser treatments? If yes, please specify.

What products are you currently using on your skin?

Do you have any dental or acrylic implants, crowns or bridgework? If yes, please specify.

Do you have any tattoos or permanent makeup in the area to be treated? If yes, please specify.

Do you have a pacemaker?

Have you ever been treated by an endocrinologist (hormone imbalance)? If yes, please specify.

Do you sunbathe or use self-tanning lotions or use tanning beds? If so, then how often?

Have you ever had gold therapy (used for rheumatoid arthritis)?

Are you currently pregnant?

Have you had filler or Botox/Dysport injections in the area to be treated? If yes, please specify.

Do you have any particular skin sensitivities?

Your Glowtique expert today is: *

By submitting this form I understand the following:

The details I have provided are a true, complete and accurate statement of my medical history past and present. I am aware that failure to disclose information pertinent to my treatment could have serious health ramifications. I am aware that failure to disclose information pertinent to my treatment could have a direct bearing on my treatment outcome.