Client Intake Form for Electrolysis by Danielle

Client Intake Form for Electrolysis by Danielle

Please provide your personal details and health history to get started.
Full Name

First NameLast Name
Gender & Preferred Pronouns
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you had electrolysis or other hair removal treatments before?
What areas do you wish to have treated? (All areas of the body can be treated except for inside ears, nose & inner eye). Moles can be treated with written permission from a physician. Brazilian & SRS treatment will be an additional $20 an hour. For Bikini line work there is no additional charge, please ask me for more details during your consultation if interested
Do you have any of the following conditions that may affect skin sensitivity or healing

Other
Are you currently taking any medications?
If yes, please list your medications.
Do you have any allergies? (Latex, Metal etc) that may affect skin sensitivity or healing
If yes, please list your allergies.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Previous Methods Of Hair Removal
Informed Consent, Medical/pregnancy Acknowledgement & Cancellation Policy
I understand that electrolysis is voluntary in nature and is considered an elective cosmetic procedure. I have chosen to undergo treatment of my own free will and will have the opportunity to ask questions regarding the procedure, expected outcomes, treatment process and potential risks during the consultation and any future appointments
I understand that a series of treatments over 12-24 months (but possibly longer) is necessary to achieve permanent hair removal. Results vary based on my previous temporary methods of hair removal, the science of electrolysis and my individual physiological factors including hair growth cycles, hormones, skin type, medical conditions and adherence to recommended treatment schedules.
I understand that, although electrolysis is generally considered safe when preformed by a licensed professional. Potential side effects and complications may occur. They include redness, swelling, tenderness, bruising, scabbing and temporary or permanent pigment changes.
I acknowledge that successful treatment outcomes require my cooperation with all recommended pre-care and aftercare instructions. As well as adherence to scheduled treatment plans. I understand that detailed pre and post care instructions are available on the website and will also be discussed during my consultation and throughout the course of treatment
I acknowledge that if I am pregnant, believe I may be pregnant or become pregnant during the course of treatment, it is my responsibility to notify the Electrolysis by Danielle immediately. Treatment decisions during pregnancy will be made at the sole discretion of the electrologist and requires a physician approval prior to continuing treatment.
I acknowledge my health history and information is accurate to the best of my knowledge. In order to provide me with safe and effective treatments I will notify Electrolysis by Danielle of any medical changes in the future.

Cancellation Policy
Your appointments and well-being is very important to me. I understand that sometimes, unexpected delays can occur and schedule adjustments will need to be made. If you need to cancel your appointment, I respectfully request at least 24hr notice.

My Policy:
- Any cancellation or reschedule made less than 24hrs before your scheduled appointment will result in a cancellation fee. The amount of the fee will be 80% of the price of the appointment time scheduled.
- I ask that you arrive just a few minutes early for your appointment. If you arrive more than 10 minutes early please text me first.
- Clients who are continually late or cancel appointments may have treatment services terminated permanently.
- For a 15 min or 30 min appointment, arriving 15 minutes late will result in the appointment being considered a cancellation and a cancellation fee will apply.
- For 1hr to 45min appointments, if you arrive 15 minutes late, you will be charged for the full appointment and that time will be deducted from your scheduled service.
- Repeated cancellations, no shows or chronic lateness may result in refusal of future scheduling at the discretion of Electrolysis by Danielle.
- Please DO NOT come to your appointment sick, always reschedule as a courtesy to me and other clients.

By signing below, I acknowledge that:

I have read, understood all of the terms & conditions above. I voluntarily consent to treatment with "Electrolysis by Danielle". I understand the risks, limitations and responsibilities associated with electrolysis treatment.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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