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Electrolysis Health Intake Form Master 2025

Electrolysis Health Intake Form Master 2025

Please fill out this form prior coming to your appointment. We will go through this intake more in depth during your complimentary consultation. 
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    • Western Sahara
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    • Other
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    We will use this number to send text appointment reminders to and appointment communication.
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    • Google Search
    • Facebook
    • Yelp
    • Instagram
    • Referred
    • Drove by
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    Pick a Date
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    For minors, under the age 18 years old, you will need a parent or legal guaridan with you.
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    Please write the person you would like us to contact in case of an emergency. We need: full name, relationship to you, contact number. By providing this information you are giving Spa Liz & Company, LLC permission to contact them in case of an emergency and to provide details of what the medical issue is. Spa Liz will still contact emergency personal first before calling the contact listed during a medical emergency. 
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    Please take photo(s) of area you would like electrolysis on at your "hairest" day. Right before you would normally remove it. Tips: Make sure it done in a well lite area. Take a picture from far away, close up, side view.
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    Check all those that apply
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    Ex: Success rate, Issues, Reactions, etc.
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    Examples: Slow onset and sparse, Abrupt onset thick and coarse
    • Slow, sparse, and light-colored
    • Slow, sparse, and thick coarse hair
    • Fast, thick, and light-colored
    • Fast, thick, and thick, coarse hair
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    If yes, please explain
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    Example: Partial Hysterotomy, Tubal Ligation
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    These medications have been known to cause or accelerate hair growth in people.
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    Ex: Aspirin, Ibuprofen, Blood Thinners
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    Please list the product name brand, how often you use it and why you use it.
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    If it is the same as face, please skip
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    If yes, please describe
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    Ex: Accutane, Retin-A (Tretinoin Gel), Avage, Tazorac, Differin (Adapalene), Other Retinoids, Hydroquinone, Acyclovir
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    Spa Liz & Co. Policies:

    • All appts are confirmed with a credit card on file.
    • Failure to submit a Health Intake Form within 72 hrs after booking may result in cancellation of the appointment.
    • Forms can be found on the service and scheduling page.
    • As a courtesy, we do try to send forms via SMS. However, if you don’t receive one, please go www.spalizandco.com/scheduling to fill it out.
    • It is up to the client to fill out the form(s) correctly and completely. Policies are still enforced even if forms are not completed and returned.
    • 24-hour notice of cancellation is required before your appointment.
    • If an appointment is canceled within 24-hours, 50% of the total service fees will be charged to the credit card on file, or an invoice will be sent before another appointment can be made. 
    • Failure to give 24-hour notice or a No Show/No Call will result in 100% of the service fees being charged to the credit card on file or invoice sent before another appointment can be made.
    • If late for an appointment (varies depending on appointment length), it will still end on time, or the appointment will be canceled and full payment required.
    • All packages expire one year from the purchase date unless otherwise noted.
    • All sales are final on products, services, and packages. Therefore, they are non-transferable, non-refundable, and cannot be substituted.
    • No one besides who the appointment is for is allowed in the spa. You will be asked to reschedule and pay the service cancellation fee if the accompanying person can not wait outside.
    • Minors receiving service must have a legal custodian/parent. Please see FAQ for more information regarding minors.
    • If you have any questions or concerns, please go to the F.A.Q. page found under the Home section at www.SpaLizandCo.com.

    Consent to Treatment:

    • I have had any questions or concerns answered before treatment today.
    • I will address any future questions with my skin therapist before treatment.
    • I give permission to my therapist to perform the facial treatment we have discussed and will hold her and her company harmless from any liability that may result from this treatment.
    • I have given an accurate account of the questions asked above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically.
    • I understand my aesthetician will take every precaution to minimize or eliminate adverse reactions as much as possible.
    • I am willing to follow recommendations made by my aesthetician for a home care regimen that can minimize or eliminate possible adverse reactions.
    • If I have additional questions or concerns regarding my treatment or suggested home products / post-treatment care, I will consult the aesthetician immediately.
    • I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures.
    • I certify that I have read and fully understand the above paragraphs and have had sufficient opportunity for discussion to answer any questions. I understand the procedure and accept the risks.
    • I do not hold the aesthetician responsible for any of my conditions that were present but have not disclosed the time of this skincare procedure, which may be affected by the treatment performed today.
    • I voluntarily agree to undergo this treatment/procedure after the nature and purpose of this treatment/procedure have been explained to me, along with the risks and hazards involved.
    • Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications.
    • I understand that it is imperative to my health and safety that I disclose all of the information requested in the Client Consultation/Health History form. I have cited all conditions and circumstances regarding my health history, allergies, medications, supplements, or prescriptions being taken (orally and/or topically), and any past reactions to products or medications.
    • I understand that no specific guarantees of the results can or have been made and that there is the possibility I may require additional treatments/procedures to obtain the expected results at an additional cost.
    • I have read and understand all pre-treatment, post-treatment, and home care instructions. I understand the importance of following all instructions given to me.
    • In the event that I have additional questions or concerns regarding my treatment or post-treatment care, I will consult the technician/esthetician immediately. I understand that if I choose to consult a physician, I do so at my own expense.
    • I understand that although electrolysis is permanent it will take a series of treatments to achieve permanency. I understand the success of my treatments will depend on my compliance with my treatment schedule, my tolerance level, inherited growth patterns, and any other instructions explained to me or recommended by the Technician.
    • I understand that photo documentation is necessary to provide an accurate record of pre-existing conditions and hair growth extent. I understand these photos will never be used for marketing purposes without my permission.

     

    3/2/2022

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