Client Consent Form
Today's Date: October 6, 2022
Female Clients Only:
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.
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.
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.