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Client form
Large Volume Electrolysis
Please enable JavaScript in your browser to complete this form.
Which area(s) would you like treated?
*
Face/Neck
Genital
Both Face/Neck and Genital
Legal Name
*
First
Last
Preferred Name
Are you completing this form for someone under 18 years of age?
*
Yes
No
Name of Parent or Legal Guardian
*
First
Last
Gender
*
Date of Birth
*
Phone
*
Email
*
Email
Confirm Email
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
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Connecticut
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District of Columbia
Florida
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Idaho
Illinois
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Iowa
Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Montana
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Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Emergency Contact Name/Phone/Relationship
*
Notes for calling
(example: please don't leave voicemails)
Were you referred?
*
Yes
No
If yes, by whom?
Medications/Implants/Body Mods
Please check all that apply:
Aspirin
Hormones
Natural Products
Over-the-counter meds
Antibiotics
Oral contraceptives
Anti-inflammatories
Cortisone
Anticoagulants
Dental implants
I.U.D
Metal implants
Pacemaker
Saline implants
Contact lenses
Piercings
Tattoos
Current Medications
Medical Conditions
Please check all that apply:
Epilepsy
Persistent bleeding
HIV+
AIDS
Scars
Nervous disorder
Arterial disease
Menopause
Thyroid conditions
Hepatitis (A/B/C)
Hemophilia
Herpes
Diabetes
Pregnancy
Vitiligo
Circulation problems
Cancer/Remission
Skin cancer
Infectious disease
Asthma
Acne
Pigmentation issues
Healing problems
Nerve damage
High blood pressure
Other Medical Conditions
Allergies
Please check all that apply:
Cosmetics
Iodine
Latex
Metal
Medications
Food
Environment
Animals
Fragrance
Skin care products
Other Allergies
Skin Treatments
Have you undergone any of the following treatments?
Please check all that apply:
Laser
Chemical peels
Accutane
Surgeries
Have you had in the past 90 days, or will you have within the next 90 days, any surgery involving the treatment area(s)?
*
Yes
No
Do you have written approval from your doctor to have electrolysis in the affected area(s)?
*
Yes
No
Temporary Hair Removal
Have you used in the past, or are you currently using, any of these methods of temporary hair removal in the area(s) to be treated?
Please check all that apply:
Shaving
Waxing
Tweezing
Threading
Bleaching
Trimming
Depilatories (ex. Nair)
Abrasives
Other
Permanent Hair Removal
Have you received permanent hair removal treatment (electrolysis)?
Please check all that apply:
Thermolysis/Shortwave/High Frequency
Blend (Combined Currents)
Galvanic
Total Hours
*
Location(s) of treatment
*
Sensitivity and result of treatment
*
Laser Hair Reduction
Have you used any methods of hair reduction?
Please check all that apply
Laser
IPL
Number of sessions
*
Location(s) of treatment
*
Reaction to treatment
*
Other Information
Is there anything else we should know?
Comments:
Hair Growth Photos
*
Click or drag files to this area to upload.
You can upload up to 5 files.
Please upload at least 3 clear photos of your face showing 4-6 days of hair growth. Include one photo of lip, chin, and neck area and one of each side profile showing sideburn and jawline area. Please note: photos of genital area are not required.
Medical History Information
Name and Address of your GYN, Internist, or Family Doctor:
*
Please list all previous surgeries:
Name
Submit
