Large Volume Form - Cirine Hair Removal & Skin Care

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? *

Name of Parent or Legal Guardian *

First

Last

Gender *

Date of Birth *

Phone *

Email *

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Emergency Contact Name/Phone/Relationship *

Instructions for calling

(example: please don't leave voicemails; call after 5pm CST)

Were you referred? *

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)? *

Do you have written approval from your doctor to have electrolysis in the affected area(s)? *

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:

Client form

Medications/Implants/Body Mods

Medical Conditions

Allergies

Skin Treatments

Surgeries

Temporary Hair Removal

Permanent Hair Removal

Laser Hair Reduction

Other Information

Medical History Information

Treat yourself

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