{"id":10761,"date":"2025-11-10T08:13:36","date_gmt":"2025-11-10T13:13:36","guid":{"rendered":"https:\/\/bluecreekvalley.com\/kskinstudios\/?page_id=10761"},"modified":"2025-11-10T08:18:42","modified_gmt":"2025-11-10T13:18:42","slug":"consent-form","status":"publish","type":"page","link":"https:\/\/bluecreekvalley.com\/kskinstudios\/consent-form\/","title":{"rendered":"Consent Form"},"content":{"rendered":"\n<p>Thank you for choosing KSkin Studio! Please complete this form before your appointment. Your responses help us provide the safest and most effective care for your skin.<\/p>\n\n\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f10764-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"10764\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/kskinstudios\/wp-json\/wp\/v2\/pages\/10761#wpcf7-f10764-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"10764\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.3\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f10764-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<!-- KSKIN STUDIO \u2013 CLIENT CONSENT FORM -->\n<div class=\"kskin-consent\">\n\t<h2>Personal Information\n\t<\/h2>\n\t<p><label>Full Name* <span class=\"wpcf7-form-control-wrap\" data-name=\"fullname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fullname\" \/><\/span> <\/label><br \/>\n<label>Date of Birth <span class=\"wpcf7-form-control-wrap\" data-name=\"dob\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"dob\" \/><\/span> <\/label><br \/>\n<label>Phone Number* <span class=\"wpcf7-form-control-wrap\" data-name=\"phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"phone\" \/><\/span> <\/label><br \/>\n<label>Email Address* <span class=\"wpcf7-form-control-wrap\" data-name=\"email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email\" \/><\/span> <\/label><br \/>\n<label>Emergency Contact (Name & Phone) <span class=\"wpcf7-form-control-wrap\" data-name=\"emergency-contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"emergency-contact\" \/><\/span> <\/label>\n\t<\/p>\n<hr \/>\n\t<h2>Medical Information\n\t<\/h2>\n\t<p>Please check any conditions that apply:\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"medical-conditions\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Epilepsy\" \/><span class=\"wpcf7-list-item-label\">Epilepsy<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Heart Condition \/ High Blood Pressure\" \/><span class=\"wpcf7-list-item-label\">Heart Condition \/ High Blood Pressure<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Pregnancy or Nursing\" \/><span class=\"wpcf7-list-item-label\">Pregnancy or Nursing<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Skin Allergies or Sensitivities\" \/><span class=\"wpcf7-list-item-label\">Skin Allergies or Sensitivities<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Recent Botox or Fillers (within 2 weeks)\" \/><span class=\"wpcf7-list-item-label\">Recent Botox or Fillers (within 2 weeks)<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Use of Retin-A \/ Accutane \/ AHA \/ BHA products\" \/><span class=\"wpcf7-list-item-label\">Use of Retin-A \/ Accutane \/ AHA \/ BHA products<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Recent Chemical Peel \/ Laser \/ Microneedling\" \/><span class=\"wpcf7-list-item-label\">Recent Chemical Peel \/ Laser \/ Microneedling<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"medical-conditions[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>If Other, please describe:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-medical-info\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"other-medical-info\"><\/textarea><\/span>\n\t<\/p>\n\t<p><label>Are you currently under a dermatologist\u2019s care?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dermatologist-care\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"dermatologist-care\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"dermatologist-care\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>If yes, please explain:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"dermatologist-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"dermatologist-details\"><\/textarea><\/span>\n\t<\/p>\n\t<p><label>Have you had any recent facial surgeries or procedures?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"facial-surgery\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"facial-surgery\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"facial-surgery\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>If yes, please specify:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"facial-surgery-details\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"facial-surgery-details\"><\/textarea><\/span>\n\t<\/p>\n\t<p><label>Are you currently taking any medications (topical or oral)?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medications\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"medications\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"medications\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>If yes, please list:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medications-list\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"medications-list\"><\/textarea><\/span>\n\t<\/p>\n<hr \/>\n\t<h2>Skin Information\n\t<\/h2>\n\t<p><label>How would you describe your skin type?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"skin-type\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"skin-type\" value=\"Normal\" \/><span class=\"wpcf7-list-item-label\">Normal<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"skin-type\" value=\"Oily\" \/><span class=\"wpcf7-list-item-label\">Oily<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"skin-type\" value=\"Dry\" \/><span class=\"wpcf7-list-item-label\">Dry<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"radio\" name=\"skin-type\" value=\"Combination\" \/><span class=\"wpcf7-list-item-label\">Combination<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"skin-type\" value=\"Sensitive\" \/><span class=\"wpcf7-list-item-label\">Sensitive<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>What are your primary skin concerns?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"skin-concerns\"><span class=\"wpcf7-form-control wpcf7-checkbox\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Acne \/ Breakouts\" \/><span class=\"wpcf7-list-item-label\">Acne \/ Breakouts<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Dryness \/ Dehydration\" \/><span class=\"wpcf7-list-item-label\">Dryness \/ Dehydration<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Hyperpigmentation \/ Uneven Tone\" \/><span class=\"wpcf7-list-item-label\">Hyperpigmentation \/ Uneven Tone<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Aging \/ Fine Lines\" \/><span class=\"wpcf7-list-item-label\">Aging \/ Fine Lines<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Redness \/ Sensitivity\" \/><span class=\"wpcf7-list-item-label\">Redness \/ Sensitivity<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"skin-concerns[]\" value=\"Other\" \/><span class=\"wpcf7-list-item-label\">Other<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>If Other, please specify:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"other-skin-concern\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"other-skin-concern\" \/><\/span>\n\t<\/p>\n\t<p><label>Do you have any allergies (including skincare ingredients or latex)?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergies\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><label><input type=\"radio\" name=\"allergies\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"radio\" name=\"allergies\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/label><\/span><\/span><\/span><br \/>\n<label>If yes, please list:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"allergies-list\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"allergies-list\"><\/textarea><\/span>\n\t<\/p>\n\t<p><label>What skincare products do you currently use?<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"skincare-products\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"skincare-products\"><\/textarea><\/span>\n\t<\/p>\n<hr \/>\n\t<h2>Teen Facial \u2013 Minimum Age Policy\n\t<\/h2>\n\t<p>Please note that our Teen Facial services are available only to clients who are at least 14 years old (the \u201cMinimum Age\u201d).\n\t<\/p>\n\t<p>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.\n\t<\/p>\n\t<p>If you are under the Minimum Age, you are not permitted to:\n\t<\/p>\n\t<ul>\n\t\t<li>\n\t\t\t<p>Use or provide any information on our website\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>Register for an account\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>Make any purchases through our website\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>Share any personal details, including:\n\t\t\t<\/p>\n\t\t<\/li>\n\t<\/ul>\n\t<p><label>Full Name <span class=\"wpcf7-form-control-wrap\" data-name=\"TeenFullName\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"TeenFullName\" \/><\/span> <\/label><br \/>\n<label>Home or billing address <span class=\"wpcf7-form-control-wrap\" data-name=\"TeenHomeOrBillingAddress\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"TeenHomeOrBillingAddress\" \/><\/span> <\/label>\n\t<\/p>\n\t<p>Thank you for helping maintain a safe and appropriate environment for all clients.\n\t<\/p>\n<hr \/>\n\t<h2>Treatment Consent\n\t<\/h2>\n\t<p>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:\n\t<\/p>\n\t<ul>\n\t\t<li>\n\t\t\t<p>I have disclosed all relevant health and skin information.\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>I will inform my esthetician of any discomfort during treatment.\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>Certain products or procedures may cause mild redness or irritation.\n\t\t\t<\/p>\n\t\t<\/li>\n\t\t<li>\n\t\t\t<p>My esthetician may recommend home care products for optimal results.\n\t\t\t<\/p>\n\t\t<\/li>\n\t<\/ul>\n<hr \/>\n\t<p>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.\n\t<\/p>\n\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"consent-agree\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first last\"><label><input type=\"checkbox\" name=\"consent-agree[]\" value=\"I agree to the terms and consent to receive skincare services from KSkin Studio.\" \/><span class=\"wpcf7-list-item-label\">I agree to the terms and consent to receive skincare services from KSkin Studio.<\/span><\/label><\/span><\/span><\/span>\n\t<\/p>\n\t<p><label>Signature (type full name)*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"signature\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"signature\" \/><\/span>\n\t<\/p>\n\t<p><label>Date*<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"consent-date\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"consent-date\" \/><\/span>\n\t<\/p>\n<hr \/>\n\t<div class=\"wpcf7-form-control wpcf7-power_captcha_recaptcha wpcf7-validates-as-required wpcf7-form-control-wrap\" data-name=\"power_captcha_recaptcha-104\"><div class=\"pwrcap-wrapper\" data-context=\"pwrcap_cf7_render_captcha\"><\/div><\/div>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit Consent Form\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":"<p>Thank you for choosing KSkin Studio! Please complete this form before your appointment. Your responses help us provide the safest<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-10761","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/pages\/10761","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/comments?post=10761"}],"version-history":[{"count":4,"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/pages\/10761\/revisions"}],"predecessor-version":[{"id":10768,"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/pages\/10761\/revisions\/10768"}],"wp:attachment":[{"href":"https:\/\/bluecreekvalley.com\/kskinstudios\/wp-json\/wp\/v2\/media?parent=10761"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}