Required New Client Intake Form

NEW CLIENT INTAKE FORM

*Required to be submitted prior to first service with Rachel Barosko
Name

First NameLast Name
Date of Birth

MonthDayYear
Today’s date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
(do I have permission to contact you with offers & information on treatments & products?)
Are you pregnant or hoping to be in the next 6 months ?
Do you have any of the following conditions :
Please list any other health conditions that I should be aware of:
List any allergies or sensitivities that you may have :
List any prescribed skin medications or topical creams that you are using :
Please list your full skincare routine with names of products included :
Are you currently using any of the following?
Do you wear spf daily?
Do you tan regularly? (In the sun or on tanning beds?)
What is your main skin care concern and what would you like to improve?
Examples: aging, acne, hyperpigmentation, redness
Please select which applies to you :
Please select which applies to you :
Do you consent to photos and/or videos of your facial treatment being taken? This is for purpose of tracking progress and/or marketing purposes.
YES/NO
It is your responsibility to inform Rachel Barosko of any pre-existing and all health conditions. It is also your responsibility to inform Rachel Barosko of any discomfort during any service.

I understand and accept any risks of which I have been advised associated with the agreed upon skin treatment. I release Rachel Barosko from all liability arising from any injury and/or damage from failure to inform Rachel Barosko of any pre-existing conditions, limitations, specific sensitivities, and/or any discomfort during the service. I agree to keep Rachel Barosko updated as to any changes in my medical profile.
Signature Required:
Should be Empty:

NEW CLIENT INTAKE FORM