Electrolysis Questionnaire

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Post Code

E-mail*

example@example.com

Phone Number*

Date of Birth*

DayMonthYear

Have you had previous laser and or electrolysis? If so, please explain.*

YesNo

Please provide details

What areas are you looking to have Electrolysis? *

Do you have any Hormonal imbalances? If so please explain.*

YesNo

Please provide details

When was the last time you were exposed to the sun ?*

This weekPast 2 weeksNo exposure in past Month

Please provide details

Are you using any retinols/ hydrocortisone/ Retin-A/ bleaching cream or any prescription Topicals on skin? If so please, explain.*

YesNo

Please provide details

Any cosmetic tattoos/ permanant makeup in area being treated? *

YesNo

Have you taken any antibiotics in the last 14 days?*

YesNo

Please provide details

Are you taking any prescribed medications or dietary supplementation?*

YesNo

Please provide details

Are you waxing, tweezing, shaving, or doing any depilatories on the area you want treated? If yes, please specify what you are doing and how often hair is being removed.*

YesNo

Please provide details*

Are you pregnant or breastfeeding?*

YesNo

Have you had any Botox, Dermal Fillers, Skin Resurfacing, or Chemical Peels in the past 6weeks?*

YesNo

Please provide details

History of HSV (Cold sores/ Fever Blisters)

YesNo

Do you have any other medical conditions, injury or any other information that we (Electrologist) should be aware of that we have not mentioned?*

YesNo

Please provide details

CONSENT FORM
Electrolysis treatments are a form of electrical epilation with a minimal amount of current being delivered to the root of the hair to destroy it through a variety of modalities. All modalities will treat only the offending hair follicle, making this a non-invasive and more direct route to target unwanted hair. ONLY ACTIVELY GROWING hairs and follicles can be treated by an electrologist and multiple sessions will be necessary.
Galvanic Electrolysis: Galvanic Electrolysis is the oldest type of electrolysis. The Direct Current used is extremely effective but very slow. It creates a chemical change in the follicle to disable the root.
Thermolysis Electrolysis: Thermolysis uses shortwave radio frequency or AC current. Thermolysis causes the water molecules by your hair to rapidly vibrate, which produces heat. When enough heat is created, thermolysis damages the cells that cause hair growth.
Blend Electrolysis: True to its name, blends and combines both Galvanic and Thermolysis in one treatment. If one type of electrolysis doesn't kill your unwanted hair the other method will.

What to expect
A common experience is redness, swelling, bruising or all of the above. These are all natural reactions from the stimulation applied to follicle. It can be eased with the use of an ice pack and after treatment gel 2-3 times daily. In order to prevent any additional reaction, it is critical that you inform us of any medical conditons, medications, supplements, lotions and oils.
Post Treatments
Avoid Direct Sunlight
Avoid exercise and or anything that may cause sweating within 24hours.
Keep area washed and clean
Use ice-pack if necessary
After Treatment-Gel is recommended 2-3 times daily
DO NOT pick, rub or scratch area (scabbing is normal and part of healing process.

I understand that the treatment is not guaranteed due to risks of complications both known and unknown to myself and the electrologist.*

Yes

I understand that results are reliant on the accuracy of information I have provided the Electrolysis Center regarding my medical history and my adherence to proper before and after care.*

Yes

I understand that possible side effects may include but are not limited to: Inflammation to the hair follice. Edema (Swelling) Purpura (Bruising). Redness after treatment. Change in Pigmentation. Small Blisters and or pinpoint bleeding (possible scarring if these are aggravated.)*

Yes

I understand that the frequency and longevity of treatments is determined solely on my body's natural hair growth and therefor not predetermined by the Electrolysis Center.*

Yes

I understand and comply with Electrolysis Center 24 hour cancellation policy, that, if I am a LATE CANCEL, LATE TO APPOINTMENT or a NO CALL NO SHOW I will be charged the entirety of my appointment and will pre pay for the next appointment.*

Yes

I Acknowledge that Electrolysis Center will keep card on file for future appointments for contactless payment and for the cancellation policy as stated above.

Yes

I Acknowledge that I have read, understand and accept the terms above regarding Electrolysis Hair Removal. I hereby consent to and authorize the electrologist(s) to perform Electrolysis Hair Removal treatments related to before and after treatment services on me.*

Yes

Signature*

I (your name) your name* understand that I will have before and after photos taken for the technician at Electrolysis Center files to track progress of treatment.

I consent to give permission to use these photos for advertising and marketing. Photos to be used will be strictly of areas being treated. (Not to include identifying facial/ body features)

YesNo

I (your name) your name, Grant permission to the Electrolysis Center and its agents and employees the irrevocable and unrestricted rights to reproduce the photographs and/ or video images taken of me, during my treatment, for the purpose of: publication, promotion, illustration, advertising, or trade, in a legal manner. I hereby release the Electrolysis Center and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during the capture/ recording moments, without my name, for the purpose of advertising publicly without restriction. I waive my right to any compensation.

I acknowledge that I am:

Over the age of 18The Legal Guardian of the following

If Legal Guardian or client (s) Please list name(s) your name . blank