Glorious Skin Clinic

Please fill out this form on your first appointment.
Your answers will better help us to meet your needs and ensure that you have a happy and satisfying experience.

Appointment Day & Time

Date

Time

Full Name Address

Zip / Postal Code

State / Province

City

Date of Birth

Phone

Emergency Contact Phone

Yes No

(Your email address will be used for appointment confirmations, and quarterly newsletters) If you would like to subscribe to our newsletter and promotions please select YES or NO

Have you ever had a Microneedling treatment before?

Yes No

If yes, when was that?

Do you have any special skin problems or concerns pertaining to your face or body?

Yes No

If yes, what was that?

Are you pregnant, or do you have HIV/AIDS, allergies, or any other health issues?

Yes No

If yes, explain in short What would you like to achieve from your treatment today?

Client Consultation Form

During the initial consultation, we will discuss your expectations
& talk through the different treatments that are on offer.

Email:

Our Clinic:

Call Us

Client Consultation Form

During the initial consultation, we will discuss your expectations & talk through the different treatments that are on offer.

Email:

Our Clinic:

Call Us

During the initial consultation, we will discuss your expectations
& talk through the different treatments that are on offer.