Initial Form

1
Name
First Name
Last Name
2
Date of Birth
Date
Month
Day
Year
3
Email
example@example.com
4
Will you like email notifications from revive glam studio ? If no we will only send information about appointments and not promos.
YESNO
5
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
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Armenia
Aruba
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Austria
Azerbaijan
The Bahamas
Bahrain
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Botswana
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Brunei
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Chile
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Cook Islands
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Cote d'Ivoire
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Curaçao
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Dominican Republic
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Egypt
El Salvador
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Faroe Islands
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Finland
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The Gambia
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Guam
Guatemala
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Guinea
Guinea-Bissau
Guyana
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Iran
Iraq
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Italy
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Libya
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Malaysia
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Mali
Malta
Marshall Islands
Martinique
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Mauritius
Mayotte
Mexico
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Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
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Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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Tokelau
Tonga
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Trinidad and Tobago
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Tunisia
Turkey
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United States
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Uzbekistan
Vanuatu
Vatican City
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Isle of Man
US Virgin Islands
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Western Sahara
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Zimbabwe
Other
Country
6
Phone Number
Please enter a valid phone number.
7
Emergency Contact Name and Number
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Ok
8
Please list any medications, supplements that you are using or have used in the past year.
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Ok
Ok
9
Are you currently under the care of a primary physician?
YESNO
10
Please select all that apply:
Do you smoke
Pregnant
Planning to be pregnant
Do you drink
Breastfeeding
Wear Contacts
Metal Implants
Facial Piercings
Prone to migraines
Claustrophobia
High blood pressure
Prone to blood clotting
Prescription Acne Medications
Prescription blood thinners
Asthma
Diabetes
Heart Condition
Lung Condition
Back pain
Epilepsy
Hypo/Hyperthyroidism
HIV/AIDS
Infectious skin disorders
Cancer
Birth control
Recent antibiotic use within the last month
None of the above
11
Have you experienced any of these symptoms or conditions in the last two weeks?Cold sores, fungus, warts, styes, conjunctivitis (pink eye), blepharitis, rashes, cold symptoms or viral symptoms.
YESNO
12
Having an infectious skin disorder, cold, or virus can temporarily excuse you from services to protect your health as well as others. Please kindly acknowledge that you understand.
YESNO
13
Have you been under the care of a physician to be aware of your overall health within the last year?
YESNO
14
Are you currently using any products that contain the following ingredients?Glycolic acid, Lactic acid, Exfoliating scrubs , any hydroxyl acid product, or any vitamin A derivatives.
YESNO
15
Do you have any allergies?
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Small
Ok
Ok
16
Do you authorize Revive Glam Studio to use your photos for social media and promotional content?This is optional; when I take regular before and after photos, This is for you to see your transformation. This question is referring to photos for promotional content. I do not take pictures of Brazilian or bikini waxing services for your privacy.
YESNO
17
Please acknowledge that you have read and agree with the Cancellation/late/no show policy.If you have to cancel or reschedule, please do so 48 hours before your appointment because cancellations, reschedules, and no-shows after 48 hours will result in 95% payment of your service(s) with the card on file 15 minutes after your scheduled appointment time. If you must cancel or reschedule, please use the link provided in your confirmation email for the fastest resolution. Frequent abuse of this policy will result in full payment upon scheduling or being banned from scheduling further appointments.
YESNO
18
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