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About Shelly
Face
Myopulse
Microchanneling
RevitaPen
Facial Reflexology
Gua Sha
Light Therapy
Facials
Body
Testimonials
Products
Radiance Blog
Book Now
About Shelly
COVID-19 Safety Strategies
Face
Myopulse
Microchanneling
RevitaPen
Facial Reflexology
Gua Sha
Light Therapy
Facials
Body
Testimonials
Products
Radiance Blog
Book Now
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Client Consult Form
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Personal Information
Name
*
First
Last
Phone
*
Email
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Date of Birth
*
MM slash DD slash YYYY
Referred by
Pre-Treatment Questions
What is the reason for your visit today?
*
Is there any specific facial area(s) that concerns you?
Please list allergies:
Are you over 18 years of age?
*
Yes
No
Are you pregnant or nursing?
*
Yes
No
Are you taking birth control pills?
*
Yes
No
Do you wear contact lenses?
*
Yes
No
Have you taken any mood-altering drugs in the past 8 hours?
*
Yes
No
Have you been diagnosed with skin cancer?
*
Yes
No
Are you getting Botox?
*
Yes
No
If yes, date of treatment:
*
MM slash DD slash YYYY
Are you getting any other injections?
*
Yes
No
If yes, type of injection:
*
If yes, date of treatment:
*
MM slash DD slash YYYY
Have you had a chemical or laser peel?
*
Yes
No
If yes, date of treatment:
*
MM slash DD slash YYYY
Do you have trouble healing?
*
Yes
No
Are you currently undergoing radiation or chemotherapy?
*
Yes
No
Are you allergic to any metals?
*
Yes
No
If yes, which ones?
*
Do you experience frequent blemishes?
*
Yes
No
Are you taking any medication?
*
Yes
No
If yes, please list medications:
*
Are you currently being treated by a dermatologist?
*
Yes
No
If yes, for what?
*
Are you currently using or have you used in the past any of the listed medicine? (Check all that apply.)
Accutane
Azelex
Differin
Renova
Retin-A
Tazarac
Glycolic or Alphahydroxy Acid
For how long did you use the medication checked above?
Which of these products are you currently using on your face? (Check all that apply.)
Soap
Cleansing Milk
Toner
Scrub
Cream
Sunscreen
Other
How many ounces of water do you consume daily?
*
Do you ever experience? (Check all that apply.)
Flakiness
Tightness
Dryness
Have you ever experienced oily shine during the day?
*
Yes
No
Are you currently having or soon to have your menstrual period?
*
Yes
No
Have you had any cosmetic surgical procedures?
*
Yes
No
If yes, please list type and date:
*
Are you presently under a physician’s care for any skin condition or any other problem?
*
Yes
No
If yes, please describe:
*
Have you been affected by any of the following? (Check all that apply.)
Allergies
Allergic to Steel
Asthma
Clotting Disorders
Cardiac Problems
Chronic
Skin Disease
Diabetes (uncontrolled)
Eczema
Epilepsy
Fever Blister
Keloid Above Neck
Headaches — Chronic
Hepatitis
High Blood Pressure
Hyperpigmentation
Immune Disorders
Lupus
Metal Bone, Pins, or Plates
Pacemaker
Psychological problems
Skin Diseases
Other
Treatment Consent
I understand there is a possibility of short-term effects such as reddening, flakiness, and temporary irritation of the skin. These effects have been fully explained to me. Results may vary depending on individual factors, including medical history, amount of sun damage or textural problems, skin type, and my compliance with pre/post-treatment instructions. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be five as to the final result obtained, I am fully aware that my condition is of cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I confirm I am not pregnant at this time. I also completed a medical history checklist and have been informed about what I must do and “not do” before, during, or after the treatment or procedure listed above. I certify that I have been given the opportunity to ask questions and that I have read and fully understand the contents of this content form. I furthermore indemnify Total Radiance and Shelly Nigel, and hold harmless from any and all claims, demands, liabilities, judgments, costs, and expenses arising out of any claims relating to the procedure authorized herein. Total Radiance and Shelly Nigel are not responsible for any injury, allergic reactions, or any skin abrasion as a result of the service(s), or any injury on-premise.
Total Radiance and Shelly Nigel are not responsible for any injury, allergic reactions or any skin abrasion as a result of the service(s), or any injury on premise. This Waiver and Release of Liability is executed on date:
*
MM slash DD slash YYYY
Consent
Clicking on this button acts as a signature to questions answered above.
Photography Consent
I understand that the taking of before and after photographs of the said treatment or procedure(s) are a condition of such treatment or procedure(s).
I consent and authorize the use of any photographs of me for the purposes of marketing and education.
*
Yes
No
If no, may we blur out your face and/or tattoos and use the photos that way?
*
Yes
No
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