Personal Information
Full Name* Date of Birth Phone Number* Email Address* Emergency Contact (Name & Phone)
Medical Information
Please check any conditions that apply:
Diabetes Epilepsy Heart Condition / High Blood Pressure Pregnancy or Nursing Skin Allergies or Sensitivities Recent Botox or Fillers (within 2 weeks) Use of Retin-A / Accutane / AHA / BHA products Recent Chemical Peel / Laser / Microneedling Other
If Other, please describe:
Are you currently under a dermatologist’s care? No Yes If yes, please explain:
Have you had any recent facial surgeries or procedures? No Yes If yes, please specify:
Are you currently taking any medications (topical or oral)? No Yes If yes, please list:
Skin Information
How would you describe your skin type? Normal Oily Dry Combination Sensitive
What are your primary skin concerns? Acne / Breakouts Dryness / Dehydration Hyperpigmentation / Uneven Tone Aging / Fine Lines Redness / Sensitivity Other If Other, please specify:
Do you have any allergies (including skincare ingredients or latex)? No Yes If yes, please list:
What skincare products do you currently use?
Teen Facial – Minimum Age Policy
Please note that our Teen Facial services are available only to clients who are at least 14 years old (the “Minimum Age”).
We do not knowingly collect, process, disclose, or share personal information from anyone under the Minimum Age without the consent of a parent or legal guardian.
If you are under the Minimum Age, you are not permitted to:
Use or provide any information on our website
Register for an account
Make any purchases through our website
Share any personal details, including:
Full Name Home or billing address
Thank you for helping maintain a safe and appropriate environment for all clients.
Treatment Consent
I understand that the skincare treatments and services provided by KSkin Studio are intended to improve the appearance and health of my skin, but individual results may vary. I acknowledge that:
I have disclosed all relevant health and skin information.
I will inform my esthetician of any discomfort during treatment.
Certain products or procedures may cause mild redness or irritation.
My esthetician may recommend home care products for optimal results.
I hereby release KSkin Studio and its esthetician(s) from any liability associated with adverse reactions that may occur as a result of my disclosed (or undisclosed) conditions.
I agree to the terms and consent to receive skincare services from KSkin Studio.
Signature (type full name)*
Date*
