6276 Cork St., Halifax, NS, B3L 1Y9
902-478-7393

Client Medical Intake Form

    1. Today's Date *

    2. Personal Contact Information *

    3. Emergency Contact Name and Number *

    4. Have you had Covid? *

    5. Are you triple-vaccinated? *

    6. Are you currently pregnant? *

    7. What is your occupation? *

    8. Do you have medical insurance? *

    9. Have you ever had? *

    10. Last treatment Approximately *

    11. Electrolysis/Laser Practitioner's Name And Location (confidential)

    12. What area(s) did you have treated with Electrolysis? *

    13. What area(s) did you have treated with Laser? *

    14. How many Laser treatments did you have? *

    15. Are you seeking Post Laser Treatment? *

    16. What area(s) do you want Electrolysis Treatments on? *

    17. Are you currently undergoing Gender Affirming procedures? *

    18. Please indicate any Temporary Methods that apply to you. *

    19. Do you get or have *

    20. Do you have any Allergies or Sensitivities *

    21. Indicate other Allergies *

    22. Do you have a Pace Maker? *

    23. Medical Conditions *

    24. Please indicate any medications that apply *

    25. Please list names of any medications you are taking? *

    26. Skin Type *

    27. Have you ever been diagnosed with Hirsutism or PCOS? *

    28. Do you require Hair Removal From a Mole (Nevus) *

    YesNo

    Nevus: A note from your primary care Doctor or Dermatologist is required to remove hair from moles. It must state the area of the body. (ex. the mole on the face is ok for the removal of hair by Electrolysis.)

    29. Natural Hair type *

    30. Do you have skin diseases, ex. Exema or Psoriasis? *

    Cancellation Policy

    The Appointment time you have chosen is the fee you will be charged.
    The ways you can Reschedule or Cancel your appointment.
    1. Online through Scheduling System or (View My Appointments)
    2. By Telephone (time stamped) 902-478-7393 up to 48 hours before your appointment.
    After this time passes your Credit Card is Automatically Charged or an Invoice is issued.
    Same applies to No Show appointments. Appointments must be paid before the commencement of your next treatment.
    Any other form is not monitored ex. emails or direct messaging through Facebook or other social media is not accepted as a cancellation notification.
    Thank you.