Client Consult


Please complete the form below

Name *
Date of Birth *
Date of Birth
Address *
What would you like to improve?
What is your present skin regimen
Do you
Have you ever had
Do you get sores/blisters? (Cold sores/shingles)
Have you ever used
Have you had any of the following, past, or present?
Are you pregnant or trying to get pregnant?
I do fully understand all the questions above and have answered them all correctly and honestly. I understand that all services offered are not a substitute for medical care. I understand that the skin care professional will completely inform me of what to expect in the course of treatment and will recommend adjustments to my regimen if deemed necessary. I also am aware that individual results are dependent upon my age, skin condition, and lifestyle. I agree to actively participate in following appointment schedules and home care procedures to the best of my ability, so that I may obtain maximum effectiveness. In the event that I amy have additional questions or concerns regrading my treatment or suggested home product routine, I will inform my skin care professional immediately. I release and hold harmless the skin care professional Natalie Klotz, Rosarium Medical Spa, and the staff harmless from any liability for adverse reactions that may result from this treatment.