• Date*
     / /
  • Date of Birth*
     / /
  • Married:
  • If yes, anniversary date
     / /
  • Employed*
  • 1 Have you ever had a facial/treatment before?
  • 2 Have you ever had a body spa treatment before?*
  • 5 Have you ever had chemical peels, laser or microdermabrasion?*
  • 7 Have you used an acne medication?*

  • Name Products you are currently using below.

    List brand where known
  • 9 Have you used any of the following hair removal methods in the past six weeks?
  • 10 What areas of concern do you have regarding your: Skin: (Please check any that apply and explain)
  • 11  What areas of concern do you have regarding your: Eyes: (Please check any that apply and explain)*
  • 12  What areas of concern do you have regarding your: Lips: (Please check any that apply and explain)*
  • 13 Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)*
  • 14 Have you had any recent tanning bed or sun exposure that changed the color of your skin?*
  • 18 Are you lactating?*
  • 19 Male Clients Only: What is your current shaving system?
  • 20 Do you experience irritation from shaving?

  • PLEASE READ...

    I understand, have read and completed this agreement fully. 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 irritation to the skin from treatments received. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

  • Intricate Beauty by Karmella

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