Client History Consultation CHEMICAL PEEL CONSULTATION FORM Updates Glo With Ally CHEMICAL PEEL CONSULTATION FORMGeneral InformationFull NameDate of BirthAddressAddress Line 1Address Line 2CityStateZip CodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwePhoneEmailWhat is your gender Female Male Non-binary OtherEmergency Contact NameEmergency Contact NumberTheir relationship to youAre you 18 years of age or over? Yes NoMedical InformationPlease describe any specific skin concerns or areas you would like to target during the chemical peel treatmentAre you pregnant? Yes NoDo you have any active cold sores? Yes NoHave you had any recent chemical peels or facial laser treatments in the last 2 weeks? Yes NoDo you have a history of skin cancer? Yes NoHave you used Accutane in the past 6 months? Yes NoAre you currently taking any blood thinners? Yes NoDo you have any known allergies? Yes NoIf ‘Yes’, please detailMedications or supplementsOther medical conditionsSkin HistoryHistory of skin conditionsPrevious facial treatmentsCurrent skincare routineSun Exposure and TanningDo you regularly engage in outdoor activities or spend time in the sun? Yes NoHave you had any recent suburns? Yes NoDid you use tanning beds or self-tanning products? Yes NoPrevious Chemical Peel ExperienceHave you had a chemical peel before? Yes NoIf 'Yes', please provide details (type of peel, strength, results, any complications)What are your primary skin goals for today’s treatment, and what would you love to see in your skin afterward?NotesAccuracy Declaration I certify that the information I have provided is complete and accurate to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my treatment. I agree to notify Glo with Ally of any changes to my health, medications, skincare products, or other relevant information before receiving future services.Type Full Name to SignDate of SignatureI agree to the terms outlined above. YesBy checking the validation box and typing your name, you acknowledge that you have completely read and fully understand the above agreement, and that your typed name stands as your legally binding digital signature under the US ESIGN Act.Submit
