Name

First Name

Last Name

Birthdate (Month/Day)

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Can we leave a message at this number?

How did you hear about us?

Areas requested for treatment

Physician Name - Primary (This is a an important safety precaution that supports your treatment plan)

Physician Name - OBGyn

Physician Name - Specialist

Physician Name - Other

Are you currently undergoing medical treatment? If yes, what are the conditions or illnesses?

Sensitivity to Discomfort / Pain

Although many individuals can tolerate minor discomfort, we want to understand your pain threshold to ensure we can tailor our approach accordingly and make you as comfortable as possible. Please describe your sensitivity to discomfort (high, low). Providing additional context about your experiences and reactions to discomfort will also enable us to offer you appropriate support and assistance.

Medications

Do you have PCOS?

Yes

Long-term Issue?

Yes

Not Applicable

Which PCOS signs do you have?

Please check all that apply.

Irregular or missed periods

Thinning scalp hair

Acne

Not Applicable

Allergies - Do you have allergies? Please check all that apply.

Not Applicable

Allergy to Latex

Allergy to Nickel

Food Allergies

Inexpensive Jewelry

Other Allergies

Any History of Electrolysis Treatment? Dates of treatments? First? Last? Frequency of Treatments? Length of Sessions?

Is there a family history of unwanted hair?

Have you had laser treatment in the past 6 months?

Do you have hirsutism? Age of onset of hirsutism? Abrupt of slow?

Temporary Removal Practices Used in the past? Select all that apply.

Tweezers

Waxing

Threading

Laser

Depilitories

Shaving

Cutting/Clipping

Not Applicable

The information I have provided is true and complete to the best of my knowledge and I agree to inform my electrologist of changes. Electronic signature and date below (this does not commit you to treatment with Rooted Electrolysis):

Date

YYYY

I will proceed with electrolysis services only after I feel that I have received a thorough consultation and feel I can make an informed decision to proceed with my electrolysis treatment.

I understand permanent hair removal requires a series of treatments over a period of time. Success of my treatments will depend on my cooperation with my treatment schedule, tolerance and inherited hair growth pattern. I understand that recommended aftercare procedures/practices is almost as important as the treatment itself. Electronic signature and date below (this does not commit you to treatment with Rooted Electrolysis):

Date

YYYY

To accommodate as many clients as possible, and give our clients the essential experience they require, we ask you, our valued clients, to be aware of our cancellation policy.

**Cancellation Policy ** 1. Cancellations made 24 hours or more before the scheduled appointment will receive a full refund. 2. Cancellations made less than 24 hours before the scheduled appointment will be eligible for a 50% refund. **Rescheduling Policy:** 1. If you need to reschedule your appointment, we kindly ask that you do so at least 48 hours before the scheduled appointment. We will do our best to accommodate your new preferred date and time. **No-Show Policy:** If you fail to show up for your appointment without prior notice, you will not be eligible for a refund. **Refund Process:** Refunds will be processed using the original payment method within 3-5 business days of confirming the cancellation. Please understand that our policies are in place to ensure that our team can continue providing high-quality services to all our clients and to manage appointment availability effectively.

Date

YYYY

Client Treatment Acknowledgement and Consent

Please be advised that the practice of beauty treatments, skincare, and electrolysis is an evolving field with inherent uncertainties, and specific guarantees regarding outcomes cannot be provided. It's important to recognize that individual responses to treatments can vary significantly, with some clients experiencing greater changes and improvements than others. In most cases, achieving noticeable differences requires multiple treatment sessions. Informed by this understanding, I acknowledge and accept the potential risks and hazards associated with my particular treatment. These risks include, but are not limited to, unsatisfactory results, soreness, poor healing, discomfort, redness, blistering, nerve damage, scarring, infection, changes in skin pigmentation, allergic reactions, muscle damage, and increased hair growth. Despite precautions taken during the treatment, it's acknowledged that not all potential risks can be anticipated in advance. Given the aforementioned factors, I comprehend that individual responses to treatment are variable and that specific outcomes cannot be guaranteed. Consequently, in exchange for the treatment I am receiving, I hereby commit to unconditionally defend, indemnify, and release from any and all liability the company providing the treatment, the individual administering the treatment, the insured parties, and any additional insured parties. This release extends to include officers, directors, and employees of the aforementioned entities for any results or conditions, whether known or unknown, that may arise due to the treatment I receive. I affirm that I have provided comprehensive disclosure of any relevant medication, prior complications, or existing conditions on my client intake form that could impact my treatment. I further understand and agree that any legal action arising from my treatment will be restricted to binding arbitration, utilizing a single arbitrator mutually agreed upon by both parties involved. By signing this document, I acknowledge that I have read, comprehended, and agreed to the terms outlined above. I confirm that I am of legal age (18 years or older) and provide my informed consent for the treatment in consideration.

Name

First Name

Last Name

Date

YYYY

Model Release

As part of the agreement for the treatment I have received, I hereby authorize the individual or company responsible for administering my treatment to utilize any photographic records taken during the treatment process. These records may be used for clinical and statistical studies, advertising, or promotional activities, without entailing any further compensation to me. I understand that any images used for advertising will be subject to my prior approval. The intention behind using such images is for record-keeping, progress monitoring, or showcasing the effectiveness of the services on the website. Rest assured, all personally identifying information will be safeguarded. Please provide your electronic signature and the date below.

Date

YYYY

YOUR PRIVACY IS IMPORTANT TO US

Your trust and confidence in us, Rooted Electrolysis, are of paramount importance. We want to emphasize that your personal information remains entirely confidential in our care. We sincerely appreciate your decision to choose Rooted Electrolysis.

We will be contacting you soon.

Rooted Electrolysis

New Client Health Assessment Form

ROOTED ELECTROLYSIS