Cryotherapy Medical Intake Form 1. First Name * 2. Last Name * 3. Address * 4. Apartment / Suite (optional) 5. Email * 6. Phone # * 7. Gender (select one) * MaleFemaleNon-BinaryGender Diverse 8. Birthday * 9. Emergency Contact Name & Phone Number * 10. Were you referred by someone? 11. What is your occupation? * 12. Are you currently pregnant? * 13. Do you have any of the following medical conditions? * Diabetes ___ Type I ___ Type IIPacemakerThyroid issuesHistory of cancer (especially skin cancer)Skin cancerPre-malignant molesRosacea (in the treatment area)Keloid / raised scars (in the treatment area)Suspicious unrecognised skin growthsVascular issuesAny recent use of Accutane® or Retin-A®EpilepsyHeart conditionsBlood pressureLupusAbdominal surgeryCold soresGenital herpesHIVCold intoleranceInfections accompanied by a feverAcute chemotherapy or radiotherapyNone of the above 14. Have you had COVID-19? * YesNo 15. Do you require treatment on a mole (Nevus) * YesNo Nevus: A note from your primary care Doctor or Dermatologist is required for any treatment on moles. It must state the area of the body. (ex. the mole on the face is ok for the removal of hair by Electrolysis.) 16. Please list the names of any medications you are taking: * 17. Are you taking any of the following medications? * InsulinBlood pressure medicationsWarfarinAspirin dailyBirth control or IUDHomeopathic remediesNone of the above 18. Do you have any of the following allergies or sensitivities? * Stainless steel / metal allergyPolysporin or topical antibioticAlcoholNone of the above 19. Please indicate any other allergies: * 20. Skin Type (check all that apply):* SensitiveNormal to dryOily 21. Do you have any skin conditions, such as eczema or psoriasis? * 22. Have you had any aesthetic procedures in the treatment area within the last 6 months? * 23. Any existing or recent illness? * 24. Any recent hospitalization or surgery? * 25. Do you have medical insurance? * Cancellation Policy The appointment time you have chosen is the fee you will be charged. The ways you can reschedule or cancel your appointment are: 1. Online through scheduling system or ("View My Appointments") 2. By telephone (time-stamped) at 902-478-7393 up to 48 hours before your appointment. After this time passes your credit card is automatically charged or an invoice issued. Same applies to no-show appointments. Appointments must be paid before the commencement of your next treatment. Forms or requests (other than this one) are not monitored (e.g. e-mails or messages sent through Facebook or other social media sites will not be accepted as a cancellation request). Thank you. I agree to inform Brooks Electrolysis Ltd. of all changes in my physical conditions (as described above). I confirm that the above information is true and correct. And I hereby give consent to the processing of my personal data.