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Electrolysis Health Intake Form Master 2022
Please fill out this form prior coming to your appointment. We will go through this intake more in depth during your complimentary consultation.
65
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1
Name
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First Name
Last Name
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Address
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Togo
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Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
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Tuvalu
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Ukraine
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United Kingdom
United States
Uruguay
Uzbekistan
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Venezuela
Vietnam
British Virgin Islands
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US Virgin Islands
Wallis and Futuna
Western Sahara
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Zambia
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Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email
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example@example.com
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Sign up for Spa Liz's newsletter to learn more about your skin, new services and specials!
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Yes, subscribe me to this newsletter.
No thank you
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Cell phone number:
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We will use this number to send text appointment reminders to and appointment communication.
Area Code
Phone Number
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How did you hear about us?
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Google Search
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Referred
Drove by
Google Search
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Referred
Drove by
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7
If referred, by whom:
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8
Birth date:
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Month
Day
Year
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9
Age:
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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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Gender
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Female
Male
Transgender M > F
Transgender F > M
Self-described
Prefer not to say
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11
Emergency Contact
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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12
What is your profession?
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13
What area/s do you have a concern with?
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Take Photo
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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15
Take Photo
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16
Take Photo
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17
Take Photo
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18
What temporary hair removal methods have your tried?
*
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Check all those that apply
Tweezing
Waxing
Electrology
Sugaring
Laser
Threading
Depilatory Cream
Shaving
Trim
Hair Inhibiting Product OTC
Hair Inhibiting Product Prescribed
Other
N/A
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19
If other, please explain:
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20
When did you last remove the hair in the area of concern? How often do you remove hair?
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21
If you did your normal method of hair removal today, how long before hair could be felt growing out of the skin?
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22
Have you had electrolysis treatments in the past? If yes, when were you last treated, what area was treated, and for how long were you receiving treatments?
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23
Anything you want to share or I should know about regarding prior treatments you have tried?
Ex: Success rate, Issues, Reactions, etc.
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What was your age when you noticed onset of the hair?
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The initial onset of the hair was?
*
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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
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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26
Family History of Similar Hair Pattern?
*
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YES
NO
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If other family members have similar hair pattern, please explain relationship to you (ex: paternal aunt, happened during menopause)
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28
Has hair pattern changed in the Last 5 years?
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YES
NO
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29
Are your menstrual periods regular?
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YES
NO
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30
If your periods are irregular, how many per year do you have? Do you need to be on medication to bring them on? Do you know the cause?
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Are you in any phase of menopause? Onset? Was it medically induced and/or are you on any medication especially for this?
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32
Are you pregnant or trying to get pregnant?
Yes, I am pregnant
No, I am not pregnant
I am trying to become pregnant
I have had a baby within the year
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33
Do you have any children? If yes, how many?
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Any difficulty carrying or conceiving?
If yes, please explain
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35
Do you have a hormone or endocrine disorders? If yes, please explain.
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36
Have you had any surgeries or procedures? If yes, please explain and what year it occured?
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Example: Partial Hysterotomy, Tubal Ligation
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37
Last medical exam?
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38
Please check all diseases, conditions & lifestyle issues/habits that apply:
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39
If yes to any of the above, please explain below:
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40
Do you have any tattoos? When was your last tattoo?
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41
Please check all allergies that apply:
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42
If yes to any of the above, please explain below?
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43
Are you on any medication types, listed below:
*
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These medications have been known to cause or accelerate hair growth in people.
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44
If yes to any of the above, please explain below?
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45
Please list all prescribed or OTC medications, vitamins/supplements, or herbals you are currently taking.
Ex: Aspirin, Ibuprofen, Blood Thinners
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46
Have you had any cosmetic procedures?
Botox
Dermal Fillers
Juvederm
Collagen
Chemical Peels
Perlane
Silicone
Dysport
Microdermabrasion
Dermplaning
Restylane
Radiesse
Sculptra
LED Trx
Other
I have not had any cosmetic procedures one
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47
If yes to any of the above, please explain below?
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48
Have you been treated for cancer or received chemotherapy treatments in the last year? If yes, please explain:
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49
SKIN TYPE: Review the skin types below, using the Fitzpatrick Scale, and check the one that best describes your skin. This information will be used by your technician to determine the most appropriate way to approachyour treatment(s):
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I. Very fair skin; blonde or red hair; light-colored eyes; freckles common
II. FaFair-skinnedlight hair, light eyes
III. Very common skin type; fair; eye and hair color vary
IV. Mediterranean Caucasian skin; medium to heavy pigmentation
V. Mideastern skin; rarely sun sensitive
VI. Black skin; rarely sun sensitive
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50
How would you describe your skin?
Normal
Combination
Oily
Dry
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51
Are you of Asian heritage (Class V) and/or have a history of keloid scarring?
*
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YES
NO
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52
Do you have any complexion concerns? If yes, please explain.
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53
What is your normal facial skincare routine?
Please list the product name brand, how often you use it and why you use it.
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54
What is your normal skincare routine on the treatment area?
If it is the same as face, please skip
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55
Do you use sunscreen daily? If yes, SPF number?
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56
When is the last time you tanned or had UV sun exposure?
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57
Do you have hyperpigmentation (darkening of the skin) or hypopigmentation (lightening of the skin) or marks after physical trauma?
If yes, please describe
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58
Do you use ANY (topical, lotions, oral antibiotics) for Cancer, Anti-Acne, Anti-Aging, hyperpigmentation products? If yes, please list them and your frequency of use.
Ex: Accutane, Retin-A (Tretinoin Gel), Avage, Tazorac, Differin (Adapalene), Other Retinoids, Hydroquinone, Acyclovir
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59
What is your activity level:
Low
Med
High
XXH
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60
Do you wear compression clothes?
YES
NO
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61
I consent to "before and after" photographs for the purpose of documentation. This may be necessary for the treatment/service.
*
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Yes
No
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62
I give permission for my "before and after" photographs to be used for:
*
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For promotional advertising in print, digital and social media with no compensation or credit.
No, I do not give permission
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63
I understand that certain risks are involved with all treatments and that any complications or side effects from known or unknown causes could occur, and I freely assume these risks.
*
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Yes
No
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64
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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65
By signing below, I understand and agree to all the above information.
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