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Client Intake / Health Assessment Form:

First name*

Last name*

Phone*

Email*

Multi-line address

Country/Region*

Address*

City*

Zip / Postal code*

Birthday*

Month

Day

Year

Upload Picture of Treatment Area

Pre‑consultation photos are appreciated and help me better understand your treatment needs, though they are not mandatory. However, essential photos will be required to be taken during your consultation.

Do you have any known Allergies?*

YES

NO

If YES, please list allergies below:

Are you currently pregnant or breastfeeding?*

YES

NO

Do you have any active skin conditions (e.g., eczema, psoriasis, dermatitis)?*

YES

NO

Have you had any recent surgeries or injuries in the area to be treated?*

YES

NO

Are you prone to keloid scarring?*

YES

NO

Keloid scarring is when the body produces too much scar tissue, creating a raised, thick, often shiny scar that extends beyond the original injury. It’s a result of an overactive healing response and can appear larger or more textured than typical scars.

Do you have any bleeding disorders (e.g., hemophilia) or are you on blood-thinning medications?*

YES

NO

Are you immunocompromised (e.g., HIV/AIDS, undergoing chemotherapy)?*

YES

NO

Do you currently have any active infections (bacterial, viral, fungal) in the area to be treated?*

YES

NO

Have you recently tanned or had a sunburn in the area to be treated?*

YES

NO

Do you have any autoimmune skin disorders (e.g., lupus, vitiligo)?*

YES

NO

Are you diabetic?*

YES

NO

If YES, is your condition well-controlled?

YES

NO

Have you used Accutane or other strong retinoids in the last 6 months?*

YES

NO

Please list any other medical conditions or concerns not mentioned above:*

The Client understands that the following conditions maybe contraindicated to treatment: *

Including, but not limited to:

• Active skin conditions

• Recent surgeries or unhealed scars

• Prone to keloid formation

• Pregnancy or breastfeeding

• Blood disorders or use of blood-thinning medications

• Immunocompromised status

• Allergies to pigments or materials used

• Active infections

• Recent tanning or sunburn

• Autoimmune skin disorders

• Diabetes (if not well-controlled)

• Recent use of Accutane or strong retinoids

Signature*

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CONTACT INFO

ADDRESS:

KB Aesthetic Lounge

20 Executive Dr. Suite J

Carmel, IN 46032

Phone / Email:

317-989-9196

kb.loungebeauty@gmail.com

OPENING HOURS:

Mon - Fri:

8am - 9pm

Sat & Sun:

By Appointment Only

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KB Aesthetic Lounge

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