Electrolysis 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. Have you ever had any of the following treatments? * Electrolysis TreatmentsLaser TreatmentsNone of the above 14. When was last treatment approximately? * 15. What was your electrolysis / laser practitioner's name & address? (confidential) 16. What area(s) did you have treated with electrolysis? * 17. What area(s) did you have treated with laser? * 18. How many laser treatments did you have? * 19. Are you seeking post-laser treatment? * 20. What area(s) do you want electrolysis treatments on? * 21. Are you currently undergoing gender-affirming procedures? * 22. Please indicate any of these temporary methods that apply to you: (check all that apply) * TweezingWaxingThreadingEpiladyShavingCuttingDepilatory creamBleachingSugaringNone of the above 23. Have you ever been diagnosed with hirsutism or PCOS? * 24. What is your natural hair type? * StraightWavyCurlyGrey / WhiteRed 25. 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 26. Have you had COVID-19? * YesNo 27. 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.) 28. Please list the names of any medications you are taking: * 29. Are you taking any of the following medications? * InsulinBlood pressure medicationsWarfarinAspirin dailyBirth control or IUDHomeopathic remediesNone of the above 30. Do you have any of the following allergies or sensitivities? * Stainless steel / metal allergyPolysporin or topical antibioticAlcoholNone of the above 31. Please indicate any other allergies: * 32. Skin Type (check all that apply):* SensitiveNormal to dryOilyAcneRosacea 33. Do you have any skin conditions, such as eczema or psoriasis? * 34. Have you had any aesthetic procedures in the treatment area within the last 6 months? * 35. Any existing or recent illness? * 36. Any recent hospitalization or surgery? * 37. 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 hereby give consent to the processing of my personal data.
