Client Medical Intake Form 1. Today's Date * 2. Personal Contact Information * Select Gender (optional)MaleFemaleNon-Binary Birthday MonthJanFebMarAprMayJunJulAugSepOctNovDec Day12345678910111213141516171819202122232425262728293031 Year19221923192419251926192719281929193019311932193319341935193619371938193919401941194219431944194519461947194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022 3. Emergency Contact Name and Number * 4. Have you had Covid? * YesNo 5. Are you triple-vaccinated? * YesNoDouble Vaccinated 6. Are you currently pregnant? * 7. What is your occupation? * 8. Do you have medical insurance? * 9. Have you ever had? * Electrolysis TreatmentsLaser TreatmentsNone of the above 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. * TweezingWaxingThreadingEpiladyEpiladyShavingCuttingDepilatory CreamBleachingSugaringNone of the above 19. Do you get or have * ColdsoresGenital HerpesAidsNon of the above 20. Do you have any Allergies or Sensitivities * Stainless Steel / Metal allergyPolysporin or topical antibiotic70% AlcoholOtherNone of the above 21. Indicate other Allergies * 22. Do you have a Pace Maker? * YesNo 23. Medical Conditions * DiabetisThyroidEpilepsyOtherHeart ConditionBlood PressurePacemakerLupisAbdominal SurgeryNone of the above 24. Please indicate any medications that apply * InsulinBlood Pressure MedicationsWarfarinAspirin DailyBirth Control or IUDHomeopathic RemedyNone of the above 25. Please list names of any medications you are taking? * 26. Skin Type * SensitiveNormal to DryCombination to OilyAcneRosacea 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 * StraightWavyCurlyGrey / WhiteRed 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. I hereby give consent to the processing of my personal data