• Client Intake Form

    Client Intake Form

  • Please check the services you will be receiving.

  • Have you had a facial before?*
  • What are your specific skincare concerns?*

  • *If you have acne: I understand KBai Aesthetics corrective facials will only help clear out congestion and some current blemishes.  It will not prevent future congestion or blemishes.  If you need help clearing acne, we have an acne program and can schedule you for a acne clearing program first time consultation at a later date.
  • Why are you receiving a facial today? Please understand— KBai Aesthetic’s practice is to promote skin health and not relaxation. We do NOT operate as a traditional Day Spa. We are results oriented and will not engage in relaxing massages or other similar Day Spa practices.*

  • What do you use daily? *
  • KBai Aesthetics facials may contain tree nuts, gluten and dairy or have been manufactured in a plant with these ingredients.*
  • Are you currently using any products that contain:
  • Have you received chemical peels, laser services, or microdermabrasion treatments recently?
  • Have you had Botox/fillers or injections in the past 14 days?*

  • Your Medical History

  • Do you have allergies to any of the following?*

  • Have you experiences any of these health conditions in the PAST?*


  • Female Clients

  • Are you taking Oral Contraceptives?*
  • Are you pregnant or breast-feeding?*

  • Acknowledgement and Waiver

    I understand that it is unlawful to receive treatment while having a contagious illness. I understand I can not be serviced while having a contagious illness, and therefore will have to forfeit my appointment and pay the cost due. 

     

    I UNDERSTAND THAT IF I WILLINGLY ARRIVE AT MY APPOINTMENT WITH A CONTAGIOUS CONDITION, OR HAVE RECIEVED ANY MEDICAL PROCEDURE IN THE PAST MONTH, OR RECIEVED INJECTIONS, BOTOX, MICRONEEDLING OR ANY INVASIVE TREATMENT IN THE PAST 2 WEEKS, I WILL FORFEIT MY APPOINTMENT AND PAY ALL COST DUE. 

    I agree to immediately inform the esthetician if I experience any pain or discomfort during the session so that the products and/or technique may be adjusted to my level of comfort. I further understand that this service should not be construed as a substitute for medical examination, diagnosis, or treatment. I understand that estheticians are not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such.

     

    I agree to keep the esthetician updated as to any changes in my medical profile during the session and understand that there shall be no liability on the estheticians part should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session and legal action.

     

    I understand that any information provided by the therapist is for educational purposes only and not diagnostically prescriptive.

     

    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 I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof.

  • Should be Empty: