ELECTROLYSIS INTAKE & CONSENT All new Electrolysis Clients are required to complete the Intake and Consent forms 48 hours before first appointment. "*" indicates required fields Name* First Last Date Of Birth* MM slash DD slash YYYY Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Prferred Method Of Contact* Phone Call Text Email Emergency Contact (Name) Emercency Contact (Phone)How did you hear about Electrolysis & Esthetics by Joanne?* What type of work do you do? YOUR GENERAL HEALTH HISTORY - Check each condition as current, past or never:Acne CURRENT PAST NEVER Cardiovascular Disease CURRENT PAST NEVER Allergy to Metal CURRENT PAST NEVER High Blood Pressure CURRENT PAST NEVER Polycystic Ovary Syndrome CURRENT PAST NEVER Hepatitis CURRENT PAST NEVER Tuberculosis CURRENT PAST NEVER Metal Implants CURRENT PAST NEVER Warts CURRENT PAST NEVER Allergy To Asprin CURRENT PAST NEVER Cold Sores CURRENT PAST NEVER Breathing Challenges CURRENT PAST NEVER Pigment Problems CURRENT PAST NEVER Herpes CURRENT PAST NEVER Keloids CURRENT PAST NEVER Body Piercings CURRENT PAST NEVER Pregnant CURRENT PAST NEVER Allergy To Latex CURRENT PAST NEVER Cancer CURRENT PAST NEVER Diabetes CURRENT PAST NEVER Skin Tags CURRENT PAST NEVER HIV CURRENT PAST NEVER Slow Healing CURRENT PAST NEVER Pacemaker CURRENT PAST NEVER Recent Facial Surgery CURRENT PAST NEVER Bleeding Disorder CURRENT PAST NEVER Other Conditions - please explain Please describe any other medical problems or history that is not covered above. Are you applying any topical medicines currently* YES NO Name of topical using: Have you had a chemical peel or any type of proceedure in the past 14 days?* YES NO Are you currently using any Retinoid products (Tretinoin/Retin A; Renova/Differin; Tazorac/Avage; Other)?* YES NO I DID IN THE PAST If yes, what strength and How Long used? Do you have regular Collagen or Botox or other Dermal injections?* YES NO Have you recently had laser resurfacing?* YES NO List your current medications: Please describe your skin: How do you consider your skin? Sensitive Resilient Unsure HORMONE RELATED QUESTIONSAge unwanted hair growth began? Cycle Length Do you have a regular menstrual cycle? YES NO Select all that apply Fertility Changes Weight gain/loss Acne hormone/endocrine disorder Family History of similar hair growth Irregular menses Hysterectomy/endocrine disorder Menopause Scalp Hair loss Eating Disorder PREVIOUS METHODS OF HAIR REMOVALHow ofter do you remove hair?* daily weekly monthly Infrequently Previous Methods Of Hair Removal ( Check all that you have tried)* Shaving Cutting/ Clipping Tweezing Waxing/Sugaring/Threading Laser Light Based Electrolysis Bleaching Depilatories No Methods Used For each method of hair removal you've done, list the type & when last done. Describe any skin reactions you have had in the past to any hair removal methods? Your Skin's reactions to previous hair removal methods? No Reaction Redness Pigmentation Pimples Ingrown Hair infection swelling other CLIENT HEALTH HISTORY ACKNOWLEDGEMENT & AGREEMENT"Client Acknowledgment and Agreement: I certify that the information given is true to the best of my knowledge and certify that I will notify the office immediately if any changes occur in my medical history/health status. I hereby release and discharge Electrolysis and Esthetics by Joanne, LLC and its employees and agents from any and all claims that I have or may have in future in connection with my treatment relating to any procedures performed by Electrolysis and Esthetics by Joanne, LL, regardless of results. Client Signature Date "* I agree signed below:* I certify this is true. date and sign below: SIGNATURE* Date* MM slash DD slash YYYY ELECTROLYSIS CLIENT INFORMEND CONSENT TO TREATElectrolysis Client Informed Consent please read carefully and sign if you agree* I duly authorize Joanne Clarke of Electrolysis and Esthetics by Joanne, LLC to perform electrolysis on me. I understand that during electrolysis a very fine sterilized needle is inserted alongside the hair in the hair follicle. A tiny amount of electrical current is then applied through this needle to the hair root permanently ending further hair growth when the hair is in the active or anagen stage of growth. I have been specifically advised that this office has implemented infection control procedures which include: 1. Single use sterilized disposable needles. 2. A “sharps” disposal unit 3. An autoclave sterilizer as well as a disinfectant cleanser prior to sterilization for tweezers. I confirm that I have not taken Accutane for at least one year . I certify that I have been fully informed of the nature and purpose of the procedure, expected outcome and possible complications and I understand that no guarantee can be given as to the final result obtained. Many factors (especially the previous methods of hair removal) determine the number and the length of treatment required. The closer you adhere to your treatment schedule, the more effective your treatment will be. Usually this takes 1.5 to 2 years before all hair is gone permanently in the treated area. I understand compliance with treatment guidelines is crucial for optimum results. I have read and understood all information presented to me before signing this consent. In consideration for Electrolysis and Esthetics By Joanne, LLC performing this procedure, I agree that I will assume the risk and full responsibility for any all injuries, losses, or damages, which might occur to me while I am undergoing this procedure or side effects I may experience after the procedure is performed. To the maximum extent allowed by law, I agree to waive and release any and all present and future claims, suits or related causes of action against Electrolysis and Esthetics By Joanne LLC, its owners, officers, employees, or agents for negligence, injury, loss, death, costs or other injuries or damages to me as a result of this procedure. Signature* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.