←

Electrolysis Informed and Consent

Let us do this part

Today's Date:

Sun May 18 2025 09:37

Practitioner:*

Please read and answer

Have you received electrolysis previously?*

Method of treatment used previously?

Thermolysis, Blend, Electrolysis (please specify):

Needle #:

Number of previous treatments:

Condition of treated area:

Temporary Methods

Razor, Tweezers, Bleach Laser, Depilatories, Wax, Other (please specify):

Medical Information: Are you suffering from the following conditions?*

Hemophilia, Hepatitis, Metallic implants, Skin diseases, Pregnancy, Epilepsy HIV, I.U.D., Pace Maker, Circulatory
deficiency, Sensory Deficiency, Severe insulin dependent diabetes (Please specify):

Details:

Are you on any medications?**

Cortisone, Anticoagulants, Hormonal treatment, Other (please specify):

Details:

Do you have any allergies?**

Latex, Metal, Topical cosmetics, Numbing creams, Lidocaine cream, other (please specify):

Details:

Do you suffer from Hypertrichosis?**

Congenital or Acquired (please specify):

Details:

Client/Patient Consent to Treatment:*

My signature below and checkboxes at each paragraph acknowledge that I have read the following statements and
agree to receive Electrolysis treatments.

The nature and purpose of the treatment have been explained to me, and any questions I have regarding this procedure
have been explained to my satisfaction.

I do not have any of the conditions (Pacemaker, metallic implant, diabetes, pregnancy, medical condition delaying
healing process, blood thinning drugs, embolism or phlebitis) contraindicated with electrolysis treatments.

I understand that with any treatment, certain risks are involved and that complications or side effects from known or
unknown causes can occur. I freely assume these risks.

Side effects might include mild redness, extreme redness, local swelling and stinging. Most side effects are temporary
and generally subside within 1-3 weeks

I have been advised not to touch or rub treated areas, not to pick scabs, to let them fall off by themselves. I understand
that I must keep the treated area clean and use hydrating and healing products, and to avoid sun exposure for healing.
week and use total sun block on treated area until completely healed.

I have received a copy of Post-Care instructions.

I understand that I have to attach a government-issued photo ID at the end of this form due to the nature of the service
and following The Saskatoon Health Region protocols.

If you are not comfortable having certain information other than your photo ID, legal name, and date of birth visible
you may cover those areas as desired.

If you are still uncomfortable submitting an electronic copy please speak with your service provider so that they can
obtain a physical copy instead.

I have read the above explanations and treatment recommendations and understand the potential risks and benefits of treatments.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that
portion shall be severed from this contract. The remainder of this contract will then be construed as though the
unenforceable portion had never been contained in this document.

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement or, if not, that my parent or legal guardian shall sign on my behalf, and that my parent or legal guardian is in complete understanding and concurrence with this agreement.

Name:*

Address:*

Postcode:*

Date of birth:*

If you are under 18 your parent/guardian will be required

Phone #:*

Email:*

Signature:*

Sign above or type signature:

Photo ID*

Please take photo(s) of your government issued photo IDs and related paperwork.