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Client Intake Form

The following form outlines the Holsia website Client Intake Consent Form. Before your appointment, you must read, understand and agree to these terms. Please read and answer  carefully.

If we call, do you want confidentiality?
May we call you at work?
Procedure(s) desired


Do you have? (check all that apply)
Do you use? (check all that apply)
Have you had? (check all that apply)
Are you? (check all that apply)
Do you practice outdoor activities? (check all that apply)


Please read carefully, and Initial

I have read and understand these risks listed above and they have been explained to me. I DID NOT JUST SIGN THIS DOCUMENT. I certify that the information in the above questionnaire is accurate and my questions have been answered.
I accept full responsibility for any complications that may arise or result during or following the cosmetic procedure(s) to be
performed at my request.

Thanks for submitting!
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