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Facial Treatment Consent & Waiver of Liability

I understand that the facial treatment I receive is a cosmetic procedure and not a medical treatment. I have answered all questions truthfully and to the best of my ability. I confirm that I have disclosed all known medical conditions, allergies, medications, and current skincare usage to prevent adverse reactions.

- I understand that possible side effects of facial treatments may include temporary redness, sensitivity, purging (breakouts), peeling, dryness, or irritation.

- I understand that certain treatments (exfoliation, peels, enzymes, LED, etc.) may carry a higher risk of sensitivity or visible flaking, especially when contraindicated with my current routine.

- I agree to follow all post-care instructions provided to me by Glow Setters Skin Studio.

- I understand that failure to follow pre- or post-care guidance, including sun protection and product usage, may affect results or cause irritation.

- I understand that recommended homecare products are essential to maintain and enhance my treatment results. I accept full responsibility for my at-home use of these products.

- I acknowledge that results vary and no guarantees are made.

- I understand that Glow Setters Skin Studio is not a medical facility and cannot diagnose or treat medical conditions. If I experience an adverse reaction, I will seek medical attention and inform the studio immediately.

- I release Glow Setters Skin Studio, its staff, and affiliates from all liability for adverse reactions, dissatisfaction, or complications resulting from the treatment and/or withheld information.

Date: November 30, 2025

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Parent or Guardian's Email Address
Email*
Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact
First Name*
Last Name*
Emergency Contact's Phone Number*
Do you have any allergies (food, drug, environmental)?
Do you have any known allergies (food, drug, environmental)? Please be specific.*
Yes
No
Explain
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
How did you hear about us?
What best describes your visit today?
I’m looking to address specific skin concerns (corrective skincare)
I’m here to relax and enjoy a rejuvenating experience

What are your current top 3 concerns with your skin and what improvements would you like to see?

Comprehensive Health and Medical History

Have you ever had any of the following conditions? Please indicate Yes or No

Acne: *
No
Yes
Rosacea:*
No
Yes
Cold Sores / Fever Blisters: *
No
Yes
Skin Disorder (i.e. Dermatitis, Eczema, etc): *
No
Yes
Hypertrophic Scarring (i.e. Keloids): *
No
Yes
Fibroids: *
No
Yes
Polycystic Ovarian Syndrome (PCOS): *
No
Yes
Constipation: *
No
Yes
Diabetes: *
No
Yes
Cancer: *
No
Yes
HIV/AIDS: *
No
Yes
Lupus: *
No
Yes
Heart Conditions: *
No
Yes
Pacemaker / Metal Implants: *
No
Yes
Arthritis: *
No
Yes
Seizures: *
No
Yes
Severe Headaches / Migraines: *
No
Yes
Hepatitis: *
No
Yes
Bleeding Disorder (i.e. Anemia): *
No
Yes
Thyroid Disease: *
No
Yes
Are you under the care of a physician or dermatologist regarding your skincare concerns? *
No
Yes
If yes, please explain:
Are you currently menstruating or experiencing hormonal changes? *
No
Yes
Medications & Topical Products - Have you used or are you currently using any of the following (check all that apply):
Accutane (Isotretinoin) – must be off for 12 months
Retin-A/Tretinoin
Benzoyl Peroxide
Hydroquinone
Antibiotics (topical or oral)
Birth control or hormone therapy
Steroid creams or prescriptions

Please list any other prescription medications or topicals:

Please list any vitamins, supplements, or recent injectables (Botox, fillers, etc.) not already mentioned:
Media Consent Option*
I DO consent to the use of my photos/videos for Glow Setters Skin Studio’s social media and educational purposes. - I understand that any shared photos/videos will be used respectfully for marketing, educational, or promotional purposes, and my identity will remain confidential unless I give explicit permission otherwise.
I DO NOT consent to the use of my photos/videos. However, I do understand that Glow Setter’s Skin Studio still requires before and after photos for my personal record of progress.
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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