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Health Questionnaire Intake Form

Client Information:

If under the age of 18, must have guardian signature and a doctor's note.

How do you maintain the desired treatment area:
How often are you maintaining the area:
Previous Electrolysis?

Medical History / Skin Treatment (Check all that apply)

Female Medical Information:

Please indicate if any family members (parents, siblings) have experienced excess hair growth:

Current Healthcare Providers:

Please state if you are being seen by providers

Primary Care Physician:
Dermatologist:
Endocrinologist:
Other Specialized Care:

Medications:

Please list all medications you are currently taking, including prescription medications, over-the-counter medications, and supplements:

Consent to Treat: I, the undersigned, consent to receive electrolysis treatment at Bare Canvas Electrolysis. I understand that I have the right to ask questions regarding the treatment and that I can withdraw my consent at any time. I acknowledge that I am participating in this treatment voluntarily and agree not to hold Bare Canvas Electrolysis or its staff liable for any adverse effects or legal repercussions arising from the treatment provided.

Cancellation and Refund Policy: Appointments are reserved exclusively for you, and we request at least 24 hours' notice for cancellations or rescheduling. Each client is permitted one waived fee per calendar year for unforeseen emergencies. Cancellations made with less than 24 hours' notice will incur a 50% fee of the reserved service. No-shows, defined as failing to attend without prior notice, will be charged 100% of the scheduled service. A $25 fee applies to cancellations of free consultations made with less than 24 hours' notice. Clients must maintain a valid credit card on file for reservations, with fees charged automatically. Outstanding balances from late cancellations or no-shows must be paid in full before scheduling further appointments, and recurring appointments may be canceled if the balance remains unpaid after 48 hours of notification.

ALL SERVICES RENDERED ARE FINAL. WE DO NOT ISSUE REFUNDS ON COMPLETED ELECTROLYSIS TREATMENTS. IF YOU HAVE ANY CONCERNS REGARDING YOUR SKIN'S HEALING OR YOUR TREATMENT OUTCOMES, PLEASE CONTACT THE CLINIC WITHIN 48 HOURS SO WE CAN REVIEW YOUR POST-CARE PROTOCOLS AND ASSESS YOUR PROGRESS. ANY BOOKING DEPOSITS OR PREPAID APPOINTMENTS ARE FULLY REFUNDABLE IF THE SESSION IS CANCELED OR RESCHEDULED AT LEAST 24 HOURS PRIOR TO THE START TIME. IF AN APPOINTMENT IS CANCELED WITH LESS THAN 24 HOURS' NOTICE, OR IF A CLIENT NO-SHOWS, ANY DEPOSIT PAID WILL BE FORFEITED AS A LATE FEE, AND NO REFUND WILL BE ISSUED. PREPAID SERVICE PACKAGES ARE NON-REFUNDABLE ONCE THE FIRST SESSION HAS BEEN INITIATED. UNUSED PACKAGE BALANCES MAY BE TRANSFERRED TO CLINIC CREDIT AT MANAGEMENT DISCRETION.

Photography Consent: I consent to Bare Canvas Electrolysis taking photographs of my treatment for the purpose of social media and promotional materials. I understand that my identity will remain confidential, and my images may be used to showcase the services provided.

Additional Comments or Concerns:

Please share any other information or concerns you would like us to know:

Treatment Log

Date Time Area Treatment