KaraMia by Tanya

Date *

Date

Name *

First Name Last Name

Date of Birth *

Date

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

How did you hear about us? *

Walked by Facebook/Instagram Online Search Referral

If referred, by who?

Are you currently under the care of a physician? *

YES NO

Have you experiences any of these health conditions in the past or present? *

Any known allergies? *

List medications/supplements you are currently taking. *

Have you ever received any botox or fillers? if so, where and when?

Have you ever experiences claustrophobia?

YES NO

Please rate your stress level

Low Medium High None

What are your skin concerns? *

What would you say your skin type is? *

Normal (no visible blemishes, fine pores, smooth texture) Sensitive (reactive to fragrance, often irritated) Combination (oily and dry patches, oily t-zone, hormonal breakouts) Oily (enlarged pores, excessive oil) Acne (cystic or nodules) Dry (dull, visible lines and wrinkles, feels tight)

What skincare products are you using on a daily basis? *

Do you experience routine breakouts or acne? *

YES NO

Have you been diagnosed with eczema, psoriasis or rosacea? *

YES NO

Have you received any of these facial hair removal services in the last 7 days? *

Waxing/sugaring Threading Laser/Electrolysis Not Applicable

Do you currently use: *

Accutane Retin-A Prescribed topical cream Not Applicable

Please specify which product or type, if you answered YES to the question above.

Are you currently using any products that contain: *

AHA (glycolic acid, lactic acid, etc.) BHA (salicylic acid) Vitamin A derivative (retinol/retonids) Exfoliating scrubs Not Applicable

Have you ever received chemical peels, laser services, or microdermabrasion treatments? *

YES, within the last month YES, within the last 2-3 months NO

Do you?

Wear contact lenses Have a pacemaker Have metal implants Smoke Consume Alcohol Consume Caffeine Frequent tanning beds

Are you taking birth control?

YES NO

Are you pregnant or breast-feeding?

YES NO

Terms and Condtions:

I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. The treatments | receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

I acknowledge that I must adhere to KaraMia by Tanya's policies. I understand that cancellations must be done with at least 24 hours notice Failure to do so will result in the loss of your appointment deposit. I understand that after 15 minutes of tardiness, my appointment may be subject to cancellation and I will be responsible in accordance with the “ No-show” policy.

I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity.

I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions.

I acknowledge that if I fail to use a minimal sunscreen (SPF45), I am more susceptible to sunburn, skin damage & hyperpigmentation. I should avoid excessive sun exposure especially between 10am-2pm.

I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied.

I acknowledge that I should avoid the use of Retin-A type products, aggressive exfoliation, waxing, and products containing acids that are no part of the recommended take-home regimen for 2-4 weeks following treatment.

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments

I release KaraMia by Tanya and its staff of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.

Signature *

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