In order to properly prepare for your visit, please complete the following forms. Glowgirl Skincare Consultation QuestionairePlease enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Address Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPhone *Birthday Month/ DayEmergency contact : *What are your main goals for this visit?If you could wave a magic wand, how would your skin look in one month?Please tell me your current skincare regimen- what products you use, how often, etc.Do you wear makeup? If so, which brands?Please describe your skin -any history of or present acne, rosacea, melasma, eczema, psoriasis, or other diagnosed skin conditions?How stressed do you feel on a regular day on a scale from 1-5 (1 = no stress, 5 = extremely stressed)?How do you manage your stress?Please describe your sleep - do you sleep well, trouble falling asleep/staying asleep, wake frequent, how many hours of sleep, etc?How much water have you had today?How often do you get regular facials?Please list any supplements or medications you take: *Birth control history:Do you have a history of yeast infections or urinary tract infections?Any known allergies or sensitivities to any food, chemical/ingredient, animal, or substance? *What role does exercise/fitness/movement/sports play in your life?Have you ever had any medical aesthetic procedures (microdermabrasion or chemical peels),or any cosmedic procedures (Botox or Fillers), or cosmetic surgery? Please explain. *Have you ever been prescribed any form of retinoid acid (Retin-A, Accutane,etc), antibiotics, corticosteroid, or hydroquinone for your skin? If so, how long did you take it? *Any history of cancer or autoimmune or chronic disease? *Do you experience constipation, diarrhea, , gas or bloating? Please explain.Any pain, stiffness, or swelling?Any food cravings?Please share an example of a typical day of your diet -breakfast, lunch, dinner, snacks, beverages:Is there anything else you'd like to share (Medical, health issues, emotional, bodily conditions, metal plates, cold sores, herpes etc) ? The more I know, the better your results. *Knowing that homecare is a big part of achieveing radiant, glowing skin, would you like me to recommend products in order to maintain today's results?Yes, give me the scoopNo, I'm just here to relaxLearning about my clients helps me provide superior customer service. All information shared is strictly confidential.Is there anything else you want to share?I give my consent to receive treatment from this practitioner, and have answered all of the questions truthfully. *YesNoIf you have had a facial ANYWHERE before, what did you love about that facial ,and what could you live without?ADD ANY ADDITIONAL INFO YOU FEEL I SHOULD KNOWPlease click the button below to submitSubmit Glowgirl Skincare COVID -19 Consent for treatmentPlease enable JavaScript in your browser to complete this form.Name *FirstLastDate / TimeDateTimeEmail *PhoneTo proceed with receiving care,I confirm and understand the following. I understand that COVID -19 has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID -19 is extremely contagious and may be contacted from various sources. I understand COVID -19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. *Yes, I understand the statement aboveNo, I do not understandI understand that I am the decision maker for my health care. To the best of their ability, my practitioner will provide me with information to assist me in making informed choices. This process is often referred to as "informed consent" and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health careduring a pandemic. Given the current limitations of COVID -19 virus testing, I understand determining who is infected with COVID -19 is exceptionally difficult. *Yes, I agree and understand the above statement to be trueNo, I do not agree or understand this statementI understand that preventative measures and intensified sanitation protocols intended to reduce the spread of COVID -19 have been implemented. However, because this work involves close physical proximity over an extended period of time in a closed space, there may be an elevated risk of disease transmission, including COVID -19. I hereby acknowledge and assume the risk of becoming infected with COVID -19 through this treatment and give my express permission to you and the staff at your offices to proceed with providing care. *Yes, I agree and understand the above statement to be trueNo, I do not agreeI understand I may ask for a hard copy of this form ,or print a copy myself. *Yes,I understand the statement but do not require a hard copy.Yes, I understand and would like a hard copyNo, I do not understandI KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID -19 PANDEMIC. *Yes, I agree with the above statementNo, I do not agreeI CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. *YesNoI HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID -19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE. I HAVE ALSO HAD THE OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT ,AND BY SIGNING BELOW (OR CHECKING THE YES BOX) I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE. *Yes, I agree with the above statementNoSignature (if completing this in person).Date / Time *DateTimeParent or Guardian consent (in case of minor). *YesNoNot applicableI consent to receiving emails from Glowgirl Skincare ( we respect your privacy). *YesNoPlease click the button below to submit Submit