KMI School of Beauty Client Intake Form

Client Intake Form

This form must be submitted at least 1 hour before your scheduled service or you will be asked to fill out a new intake in person at your appointment.
Client Data
Are you a new or returning client*
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
If you'd like, please specify your preferred pronouns
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Service(s) are you getting?*
Emergency Contact Person*

First NameLast Name
Emergency Contact Phone Number*
Format: (000) 000-0000.
Relationship to the Client
Are you a minor or under the watch/care of a Caretaker/POA?*
Medical / History Data
Any Changes in your medical history since your last visit?*
If yes, please explain*
High/Low Blood PressureHeart issues/PacemakerDermatitis/rashesBone problemsBlood Clotting/Bleeding ProblemsLupusSprainsVaricose VeinsArthritis/FibromyalgiaSpinal Cord IssuesCold sores/VirusesPoor CirculationEpilepsy/SeizuresDry/Tight SkinDry/flaking Scalp/DandruffAny form of CancersSun/Wind BurnsSensitive SkinAthlete's Foot/Toe Fungus/Red, Itching FeetWarts/Verruca/Planter's wartsIngrown Toe NailsOpen Lesions/Wounds in area being servicedIngrown Beard HairsRingwormLice/ScabiesAlopecia or hair thinningFungal InfectionsAny Herpes SimplexesAny form of HepatitisDiabetesTicks or Twitches/Muscle SpasmsAny Breathing or Respiratory issuesNeuropathyNone of the aboveAcneOther
If Other, Please Specify*
If you selected any of the above conditions, please specify if you are being treated by a physician. If no treatment is necessary, please write N/A.*
Are you currently taking any medications?*
If yes, please list them below: (i.e. blood pressure medication, blood thinners, birth control, thyroid meds, cancer treatment, etc.)*
Please list any known allergies. (i.e. peanuts, latex, dogs/cats, pollen, aspirin, bees, etc.)
YesNo
YesNo
Do you smoke or Vape Nicotine*
Are you wearing any implantable medical devices? If yes, what are these devices?*
Did you undergo any surgery in the past 2 weeks? If yes, please indicate the name or location of the surgery:*
Service Information and History
Perm/Relaxers/Texture TreatmentsLasering/IPLGel NailsAcrylicsMicrodermabrasionFillers/InjectionsLighteners/BleachingCosmetic TattooingProducts with AHA/BHAAny form of Hair ColorNone of the aboveOther
If selected any of the above services or other, please specify if you had any negative reactions to the service.
Are you getting any nail services today? *
Do you have on Gel/No-Chip or regular polish already? Please specify so our students can be adequately prepared. *
Are you getting nail extensions?*
What length nail extensions would you be interested in?*
*KMISB Does not offer extra long nail extensions. All measurements are rough estimates, not exact. Exact lengths will be determined during your appointment.*
Do you have an idea of what shape you you'd like your nails?
What kind of polish are you looking to get today?*
Are you getting any hair services today?*
What is the current condition of your hair? (i.e. coarse/tangled, matted, straight, wavy, etc.)*
YesNo
Are you getting any facial/skincare services done?*
Are you currently using any retinols'/Vitamin A, Acne medication, or using any AHAs/BHAs, etc.?
Authorization
Waiver for consent to perform services. Please initial all before service can be performed.
- I hereby consent to the service(s) being performed and will NOT hold Kay Moriah International School of Beauty liable for any reactions from service(s) products used.
- I hereby understand that Kay Moriah ISB is a beauty school, and all services are performed by students still in training, therefore the facility and those within cannot be held responsible or liable if a service does not turn out as expected.
- I understand that I will need to follow all post-service instructions given to prevent any negative results
- I understand that Tanning beds/Sun tanning/Lighteners/Brighteners/Bleaches/Excessive water/Harsh chemicals can all have negative effects on my hair, skin, and nails and I accept full responsibility for any reactions or negative results that could occur following my service if I do any of these.
- I hereby acknowledge that I must be 18 years of age or older to receive any chemical service and am willing to show identification upon request to verify my date of birth and understand that my service can be declined if I refuse. Or I must have a parent/Guardian present at all times.
- I hereby wave all rights within State law and take full responsibility for services provided. I also understand that Kay Moriah International School of Beauty reserves the right to Refuse any service for any reason.
Yes, I consent.No, I do not consent.
Signature of Client*

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For clients under the age of 18 or are under the watch of a caretaker/POA and unable to legally consent.
Parent/Guardian Name*

First NameLast Name
Signature of Parent/Guardian*

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Student Signature _______________________________________
Instructor Signature ______________________________________
Should be Empty:

Client Intake Form

Client Data

Medical / History Data

Service Information and History

Authorization

For clients under the age of 18 or are under the watch of a caretaker/POA and unable to legally consent.

Student Signature _______________________________________

Instructor Signature ______________________________________