Summer Rose Electrolysis — Client Intake, Treatment Overview & Consent, Cancellation Policy

Summer Rose Electrolysis — Client Intake, Treatment Overview & Consent, Cancellation Policy
Date of Birth *
Full Name*

First NameNickname or name you prefer me to call you (optional)Last Name
What is your age?*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your gender?*
Contact Number*
Email Address*
example@example.com
Emergency Contact Name*
Emergency Contact Phone Number*
Are you currently taking any medications? Also please say in parentheses () what for.
Select NONE or Check what applies to you:

TRETINOIN (Retin-A) (Please STOP a week before)ACCUTANE (isotretinoin) for acne (please STOP 6 months before or scabbing will occurs at every treatment area)RETINOL (please stop a week before)Have you recently had a spray tan or self-tanner applied?Do you have any metal implants (pins, plates, screws, etc.)?AHA/BHAs or any acid product used on skin? (Stop 2-4 days before)Blood thinnersDo you see an AestheticianLaser in the past? (More than four weeks ago)Do you smokeSteroidsNONE
Select NONE or Check the conditions that apply to you:*

Cancer currentlyLess than a year since cancer treatment?Heart ConditionPacemakerEpilepsyPregnancy or breast-feedingHIV/AIDS or other immune system conditionsFrequent cold sores (Herpes Simplex Virus)Blood clotting or coagulation problemsPCOSThyroid problemsHysterectomyHormone replacement therapyMenopause or post menopauseDiabetesSeizuresAuto immuneNONEOther
Have you had electrolysis before?*

YesNo
If yes, when was your last session and how often would you go?
Skin Condition & Sensitivity; select any of the skin sensitivities or conditions that apply to you or select NONE:*

Keloid scarring or history of raised scarsSensitive skin prone to redness or irritationTendency for swelling or prolonged healingHistory of histamine reactions (e.g., hives, severe itching, in electrolysis it’s raised red bumps at the treatment sight)Risk of pitting or discoloration after skin traumaBruise EasilyOilyAcne proneDry (Drink water it will significantly improve your treatments.)Suspicious moles or moles that have been removedNONEOther
Clients with sensitivities may be at higher risk for redness, swelling, scabbing, or scarring during electrolysis. Your electrologist may recommend modified treatment techniques to minimize risk. Full healing and results may vary based on individual skin sensitivity.
Do you have any allergies (especially lidocaine/benzocaine, benzalkonium [bactine], nickel, witch hazel, aloe)?
If you have Botox please say where? (Wait 2-4 weeks before getting an electrolysis treatment if you just received an injection in the area you want treated).
Mole Treatment Policy & Consent

For safety, electrolysis CANNOT be performed on moles, raised skin lesions, or suspicious skin markings without clearance from a licensed medical professional.
Do you have mole(s) you want treated?

YesNo
I have a doctor’s note authorizing treatment of the mole(s)?

YesNoN/A
Would you like to talk more about your options to treat your mole(s)? If you don’t have a doctors note don’t worry let’s talk first.

YesNoN/A
Treatment Area(s) & Hair Preparation
What areas do you want treated?*
Hair Preparation Questions:
Do you tweeze, cut, shave, or wax the hairs you want treated?*
Important Guidelines: Hair must be grown out enough to be treated —Do not shave 3–4 days prior to treatment. Do not tweeze/wax 7–10 days prior to treatment.
End of Client Intake & Health History
Electrolysis Treatment Overview & Acknowledgement

Electrolysis is the only FDA-approved method for permanent hair removal. A fine, sterile probe delivers a precise electrical current to destroy hair growth cells without harming the skin. Treatment is personalized; multiple sessions required (12–24 months for full results). Side effects are usually mild and temporary: redness, swelling, scabbing, warmth, irritation, rare scarring/discoloration. Proper aftercare is essential.
Treatment Overview / Risks / & Consent to Treat
Treatment Overview
- Electrolysis is a method of permanent hair removal that uses electrical current to destroy the growth cells of the hair follicle.
- Multiple sessions are required.
- Temporary redness, swelling, white pustules, or pinpoint scabbing may occur.
- Rare but possible risks include: infection, hyperpigmentation, hypopigmentation, and scarring.
Aftercare Instructions
- Keep treated area clean and avoid touching.
- Do not tweeze or wax between sessions.
- Avoid tanning, makeup, saunas, direct sun, or excessive sweating for 24–48 hours.
- Apply soothing products as recommended (witch hazel, aloe vera).
End of Treatment Overview & Consent to Treat
Cancellation Policy
- Appointments: Please arrive on time. Late arrivals may shorten your session.
- Cancellation/Reschedule Within 24 Hours: Appointments canceled with less than 24 hours’ notice will be charged 50% of the scheduled service.
- Failed Appointment (no call/no attendance): Will be charged 75% of the scheduled service.
Late Payment Policy
- Unpaid balances may cancel or prevent future appointments
Confirmation & Reminder Texts
- Confirmation text sent same day as appointment scheduling
- 24-hour reminder text sent day before appointment
- Clients responsible for verifying date/time on text reminders; discrepancies must be reported 24 hours prior
- Text the appointment reminder text to reach me fast or via business number
Late Arrivals & Accessibility
- Arrive on time; late arrivals will have remaining time used for treatment
- No reduction in cost or extension of treatment time
- Extra time for mobility/accessibility is included within the session
Appointment Time Modifications
- Except first consultations, appointment times cannot be changed upon arrival without 24-hour notice
- Use booking website for availability and reschedules; do not request cancellations/reschedules via message
Frequent Reschedules or Cancellations
Clients who frequently reschedule may be scheduled farther out to ensure availability

Payments & Pricing
- Payment is due at time of treatment
- Accepted forms: Cash, Check, Venmo, Apple Pay, Debit/Credit
- Pricing Disclaimer: Please be aware that service prices may fluctuate over time due to changes in business or supply costs. Clients will receive notice of any updates.
Communication Policy
- Phone calls are not answered during sessions
- Voicemail or text messages will be returned within 24 hours
End of Cancellation Policy
Client Consent & Acknowledgment
By signing below, I understand and agree to the following disclosed in the Client Intake, Treatment Overview, Consent to Treat & Cancellation Policy:
✔️Electrolysis is a form of permanent hair removal but requires multiple sessions.
✔️Temporary side effects may include redness, swelling, pinpoint scabbing, or tenderness.
✔️Rare risks may include pigmentation changes or scarring.
✔️Results vary depending on consistency, skin type, and health factors.
✔️I have disclosed all relevant and accurate health and medical information truthfully.
✔️I release Summer Rose Electrolysis from liability for any undisclosed conditions that may affect treatment.

✔️I agree and will abide to the Cancellation Policy
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Summer Rose Electrolysis — Client Intake, Treatment Overview & Consent, Cancellation Policy

Mole Treatment Policy & Consent

Treatment Area(s) & Hair Preparation

Hair Preparation Questions:

Electrolysis Treatment Overview & Acknowledgement

Treatment Overview / Risks / & Consent to Treat

Cancellation Policy

Client Consent & Acknowledgment