Virtual consultations

Consult Form For Virtual Skin Evaluation (Skincare & Regimen)
Cant make it for in office treatments or looking to prep your skin prior to coming in so that you can receive advanced treatments on your first visit no worries! Become a virtual client and receive an online personalized evaluation to treat your skin concerns at home. This service includes an email with a comprehensive skin analysis, tailored product recommendations, step by step care instructions, and much more. A $75 one-time fee. Complete the consultation form to the best of your ability. Kindly be aware that it may take 2-5 business days to receive your skincare recommendation and instructions for AM/PM usage, This will be sent via email. Your patience is appreciated. INCLUDES: A detailed skin analysis via email | Tailored product recommendations with step by step instructions to treat your skin from home | 1-2 follow ups ( INCLUDES ONE VIRTUAL CALL) SKINCARE PRODUCT RECOMMENDATIONS MUST BE PURCHASED SEPERATLY
Are you looking to receive in person treatments in the near future?
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
YOUR SKIN
What are your skin care goals?
What are your skincare challenges?

Other
Please go into more detail
Could you please provide some insights into your lifestyle? For example, do you travel frequently, workout (if so how many times a week) or engage in public speaking? This information will assist me in recommending the most suitable products for you.
Provide a picture of the left side of your face

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Provide a picture of the right side of your face

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Provide a picture of the center of your face

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Upload picture of your current skincare

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Does your skin feel sensitive when trying new products or sensitive in general
Have you ever received in clinic treatments such as chemical peels, microneedling etc?
Do you pick at your skin when you experience breakouts?
YOUR HEALTH
Have you experienced any of these health conditions in the past or present?
DO YOU TAKE ANY OF THE FOLLOWING SUPPLEMNTS

Other
If other please list
ANY KNOWN ALLERGIES

Other
Do you use sunscreen regularly?
Are you aware that sunscreen must be reapplied every 2-3 hours for ultimate skin protection? Behind the bottle usually tells you how long your skin is protected before reapplying is needed.
Have you been prescribed any medications ( topical or oral) for acne/ acne control?
If so, please list
ARE YOU A SMOKER
DO YOU DRINK ALCOHOL
DO YOU DRINK MORE THAN 4 CAFFEINATED BEVERAGES A DAY? ( TEA, COFFEE, ENERY DRINKS, SODA)
RATE YOUR STRESS LEVEL
FEMALE CLIENTS
Are you taking birth control?
Are you pregnant or trying to become pregnant?
Recently had a baby and currently breast feeding
Any menopause issues?
We're excited to showcase your before-and-after photos on our page to demonstrate the effectiveness of a Professional skincare tailored for you. This will help potential clients who may be hesitant, see how successful and remarkable the results can be with a curated regimen. Do you mind if we share your progress on our social media?
Upon receipt of the completed form and payment, you will receive a personalized skincare regimen via email, including detailed information. Links will be included to guide you to purchase the recommended skincare products. Thank you for choosing THE GLO ASYLUM for your skincare needs.
CHOOSE TIME AND DATE FOR VIRTUAL CONSULTATION ( THIS IS OPTIONAL)
Signature

My Products

Virtual Skincare Consultation/ Evaluation & Regimen

One time payment and 1-2 follow ups with Adrienne, optional virtual consultation, Receive Custom Treatment Plan in 2-5 business days via email

$75.00 Quantity

Total

Payment Methods

Credit Card

Apple Pay

Google Pay

ACH Bank Transfer

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Consult Form For Virtual Skin Evaluation (Skincare & Regimen)

YOUR SKIN

YOUR HEALTH

FEMALE CLIENTS

Upon receipt of the completed form and payment, you will receive a personalized skincare regimen via email, including detailed information. Links will be included to guide you to purchase the recommended skincare products. Thank you for choosing THE GLO ASYLUM for your skincare needs.

My Products

Payment Methods