Virtual Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

bareGlo is result-driven esthetics is that okay with you?* This field is required.

YESNO

5

Are you looking to invest in skincare?* This field is required.

YESNO

6

Are you currently living in the U.S. ?* This field is required.

YESNO

7

What state?* This field is required.

8

What Country if not the U.S.? Please put n/a if you're located in the U.S.* This field is required.

9

What would you like to share about your acne journey?* This field is required.

10

What's your level of acne?* This field is required.

Occasional Breakouts

Light Breakouts

Consistent Breakouts

Severe Breakouts

11

Add Photos* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

12

Can you commit to 6 months for your results?* This field is required.

YESNO

13

Our pricing is tailored to each individual's skincare needs. Does that work for you?* This field is required.

YESNO

14

Our virtual program requires a monthly subscription of at least 6 months to do the program is that okay?* This field is required.

YESNO

15

The consultation fee of $120 is required, once this form is finished please fill out the consultation form.* This field is required.Do you understand?

YESNO