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*
MM slash DD slash YYYY
Address*
Prferred Method Of Contact*

YOUR GENERAL HEALTH HISTORY - Check each condition as current, past or never:

Acne
Cardiovascular Disease
Allergy to Metal
High Blood Pressure
Polycystic Ovary Syndrome
Hepatitis
Tuberculosis
Metal Implants
Warts
Allergy To Asprin
Cold Sores
Breathing Challenges
Pigment Problems
Herpes
Keloids
Body Piercings
Pregnant
Allergy To Latex
Cancer
Diabetes
Skin Tags
HIV
Slow Healing
Pacemaker
Recent Facial Surgery
Bleeding Disorder
Please describe any other medical problems or history that is not covered above.
Are you applying any topical medicines currently*
Have you had a chemical peel or any type of proceedure in the past 14 days?*
Are you currently using any Retinoid products (Tretinoin/Retin A; Renova/Differin; Tazorac/Avage; Other)?*
Do you have regular Collagen or Botox or other Dermal injections?*
Have you recently had laser resurfacing?*
How do you consider your skin?

HORMONE RELATED QUESTIONS

Do you have a regular menstrual cycle?
Select all that apply

PREVIOUS METHODS OF HAIR REMOVAL

How ofter do you remove hair?*
Previous Methods Of Hair Removal ( Check all that you have tried)*
Your Skin's reactions to previous hair removal methods?

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 "*
*
MM slash DD slash YYYY

ELECTROLYSIS CLIENT INFORMEND CONSENT TO TREAT

Electrolysis Client Informed Consent please read carefully and sign if you agree*
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.