KM Beauty Aesthetics

General Beauty Intake

Your Information

First Name *

Last Name

Phone

Full Name *

Phone Number *

Date of Birth

Emergency Contact *

I am not currently pregnant or nursing

Some treatments may not be suitable during pregnancy

Allergies or Medical Conditions *

Include skin conditions, allergies, medications, or anything we should know

Are you currently taking any medications?

How did you hear about us?

Additional Notes

Photo & Social Media Consent *

May we photograph your results and share them on our social media or website?

Multi Select

I currently have Lash Extensions onI’ve had permanent make up done beforeI wear contacts or glassesI’ve had a lash lift/brow lamination done beforeI’ve had recent eye surgery Ive had recent lip fillersI’m currently using lip •plumping or exfoliating products. I’ve had threading my eyebrows/face before

I am currently using Accutine, isotretinoin or have used it recently

Client Signature *

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By signing, you acknowledge the information above is accurate

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