Client Consultation - Glow On The Go

Client Consultation Form

Please fill out the form below to help us determine whether you are a suitable candidate for our aesthetic treatments. Your safety is our top priority.

Full Name:

Email Address:

Phone Number:

Health Information

Are you pregnant or breastfeeding? Yes No

Do you have any allergies to medications, particularly to Botox, dermal fillers, or lidocaine? Yes No

Are you currently taking any blood thinners, such as aspirin or warfarin? Yes No

Do you have any of the following conditions?

Heart Disease
Blood Clots
Cancer
Autoimmune Disorders
Active Skin Infections
Keloids (Thick Scars)

Other medical conditions or medications we should be aware of:

Informed Consent

By submitting this form, I agree that the information provided is accurate to the best of my knowledge. I understand that failure to disclose any relevant health information may result in complications, and I agree to release the clinic from any liability related to undisclosed conditions.

I agree to the terms and conditions above