NEW CLIENT FORM
Welcome to Shelly's Advanced Skin Care!   It is our honor to serve you! Let's GLOW!
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Email *
Name *
When is your Birthday? *
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Address *
City *
Zip Code *
Cell Phone  *
Email *
Do you have ANY allergies that you are aware of? (Food, Environmental ect.). If yes, please list.  *
How did you hear about Shelly's?
Have you had a facial before? *
Was there anything you liked or didn’t like about a previous facial that you want me to include or avoid  today? *
Would you like to add one or more of the following services to your treatment today? (Time Permitting) *
Required
What skincare are you currently using *
Required
Have you experienced the following on your skin? *
Required
Do you use Tretinoin, Hydroquinone, Benzoyl Peroxide, or any topical pharmaceuticals? *
Do you have any special requests, areas you want me to focus or specific services you prefer (as time allows) for today’s treatment? (specific areas of extraction, method of exfoliation,)
I can go over the products I am using & recommend for you during your treatment or after.       
What do you prefer?
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Are you taking allergy medications or decongestants? *
Are you presently using Retin A or Glycolic Acid? (last 48 hours) *
Have you been waxed before? *
(Please check yes if you are using Accutane or any vitamin A derivative whether taken internally or applied topically)

Please note that some facial treatment's and waxing services have certain side effects such as skin removal, swelling, tenderness, etc.
 *

PHOTO RELEASE: It is very helpful to be able to show the amazing results of our treatments.      

 Are you willing to grant not grant permission for your aesthetician to use photos for marketing examples of their work.  

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Please Read & Initial

________________ If I have any questions, I will address these with my esthetician.  I give my permission to perform waxing procedure(s) and will hold Shelly’s Advanced Skin Care management and staff harmless from any liability that may result from this or any treatment performed. *
Please Read & Initial

  ________________ I have given an accurate account of the questions asked above including all known allergies or prescription drugs or products I am currently ingesting or using topically.  I understand my esthetician will take every precaution to minimize or eliminate negative responses as much as possible.
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Please Read & Initial

________________ I am willing to follow recommendations made by my esthetician for a home care regimen that can minimize or eliminate possible negative reactions.  In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately. *
Please Read & Initial

________________ I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures.  I understand the procedure and accept the risks.  I do not hold the esthetician or Shelly’s Advanced Skin Care responsible for any of my conditions that were present, but not disclosed at the time of the procedure, which may be affected by the treatment performed today.
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Additional things we might need to know: Medications/Allergies
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Signature *
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