Large Volume Electrolysis Consultation & Cost Estimate

Name *

First

Last

Preferred Name

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Gender *

Who can we thank for referring you? *

Were you referred? If so, please let us know who referred you.

Treatment Area(s) *

We do not treat areas other than the face/neck or genital area with this process that involves numbing injections and a single dose of IV sedation.

Allergies *

PLEASE LIST ALL KNOWN ALLERGIES.

Medications *

PLEASE LIST ALL CURRENT MEDICATIONS, INCLUDING PRESCRIPTIONS, OVER-THE-COUNTER, AND SUPPLEMENTS. ALSO INCLUDE ANY 'AS-NEEDED' MEDICATIONS.

Medical Conditions *

PLEASE LIST ALL MEDICAL CONDITIONS.

Do you use marijuana or other recreational drugs? *

Do you take Xanax or similar anti-anxiety medications? *

Have you ever had a negative reaction to anesthetics? *

Please describe.

Electrolysis History *

Please describe any and all history of electrolysis in the treatment area(s) including frequency and duration of sessions as well as the date of the most recent treatment(s).

Laser History *

Please describe any and all history of laser hair reduction in the treatment area(s) including frequency and duration of sessions as well as the date of the most recent treatment(s).

Photos

Hair Growth Photos: Face *

Click or drag files to this area to upload. You can upload up to 8 files.

To receive a time estimate for the initial clearing for the face/neck area and to book an appointment, we need to see CLEAR, CLOSE-UP, WELL-LIT PHOTOS of 4-6 days of hair growth and NO MAKEUP. ***Please include a minimum of one photo for EACH of the following areas: lip/chin, neck, left profile, right profile.*** Face/neck photos must be provided prior to booking. Photos of the genital area are not necessary.

Date / Time Hair Growth Photos Were Taken *

Date

Time

Clean-Shaven Photos: Face/Neck *

Click or drag files to this area to upload. You can upload up to 8 files.

Please upload CLEAR, CLOSE-UP, WELL-LIT PHOTOS OF YOUR CLEAN-SHAVEN FACE/NECK, WITHOUT ANY MAKEUP. Include at least one photo of each of the following areas: lip/chin, neck, left side, right side. Clean-shaven photos must be provided prior to booking.

Date / Time Clean-Shaven Photos Were Taken *

Date

Time

Request Large Volume Estimate/Consultation

Photos

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