Loading...

Client Consent Form

Today's Date: May 16, 2021

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Your Health

Have you been under the care of a physician, dermatologist or other medical professional within the past year?*
No
Yes

Yes, explain:
Any recent surgery, including plastic surgery?*
No
Yes

Yes, explain:
Any skin cancer?*
No
Yes

Yes, explain:
Have you ever had a body spa treatment before?*
No
Yes

If yes, when?
Do you smoke?*
No
Yes
Do you follow a restricted diet?*
No
Yes

Yes, specify:
Do you follow a regular exercise program?*
No
Yes
What is your stress level?*

List any medications you take regularly:

List any over the counter medications (including vitamins, herbal supplements, aspirin, etc.) you take regularly:
Do you use Retin-A, Renova, Adapalene Hydroxyl Acid, Deferin, Glycolic Acid, AHA, Salicylic Acid or Retinol/vitamin A derivative products?*
No
Yes

Yes, describe:
Have you used any of these products in the last 3 months?*
No
Yes
Have you used an acne medication?*
No
Yes

Yes, when?

Which drug?
Do you form thick or raised scars from cuts or burns?*
No
Yes
Do you have Hyperpigmentation (darkening of the skin) or Hypopigmentation (lightening of the skin) or marks after physical trauma?*
No
Yes

Yes, describe:
Do you have any special skin problems pertaining to your face or body?*
No
Yes

If yes please specify

List your daily consumption of water:

List your daily consumption of caffeine:

List your daily consumption of alcohol:
Do you experience any problems sleeping?*
No
Yes

How many hours do you typically sleep each night?
Do you wear contact lenses?*
No
Yes
Have you been exposed to the sun or used a tanning bed in the last 48 hours?*
No
Yes
How frequently are you exposed to the sun or use a tanning bed?*
Do you have any metal implants or wear a pacemaker?*
No
Yes
Have you ever experienced claustrophobia?*
No
Yes
Do you suffer from sinus problems?*
No
Yes
Have you ever had an adverse reaction after using any skin care product? (Please check any that apply)
Rash
Irritation
Peeling
Sun Sensitivity
Breakout
Have you ever had an allergic reaction to any of the following? (Please check any that apply and explain)
Cosmetics
Medicine
Food
Animals
Sunscreens
Iodine
Pollen
AHAs
Fragrance
Shellfish
Latex
Drugs
Other

If Other:

If yes, please explain:

Female Clients Only: 

Are you taking oral contraceptives?

Yes, specify:
Any recent changes to or from your contraceptive treatment?

If so, what and when?
Are you pregnant or trying to become pregnant?
Are you lactating?
Any menopause problems?*

Yes, specify:

Is there any specific concern you would like to address in your services?

Please use this space to complete answers where space was insufficient. (Please include the number of the question)

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. I am aware that it is my responsibility to inform the esthetician/skin care therapist of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release this institution and/or skin care professional from liability and assume full responsibility thereof. 

They say a picture is worth a thousand words and I would be thrilled to use yours! Nothing can beat your personal experience in representing what I do on a daily basis in the studio while simultaneously encouraging others on their own skin journey. Photos allow me to update your progress, create a positive impression of my practice and allow others who may be shy or nervous to get excited about their prospects of receiving treatments. If you enjoy what I do and want to assist on improving my small business I kindly ask that you review the following consent form with consideration.

Photo Release Form 

I grant to Kino by Kimie LLC/ Asia Yomen, its representatives, employees, providers and clients the right to take photographs of me and my property in connection with the above-identified subject. I authorize Kino by Kimie LLC/ Asia Yomen its assigns and transferees to copyright, use and publish the same in print and/or electronically. 

I agree that Kino by Kimie LLC/ Asia Yomen and affiliates may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

Permission to Use Photograph(s) and videos taken during treatment:*
I prefer that on the photos:
My first name only be used
No name be used

I understand that I can revoke this release any time in writing and that use of any of my photos or other info authorized by this release will immediately cease.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!