Electrolysis Consent Form
Please read the information below and provide your consent for the electrolysis treatment.
Full Name
First Name
Last Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please indicate the areas to be treated:
*
Face
Underarms
Bikini Area
Legs
Arms
Chest
Back
Other
Do you have any known allergies or skin sensitivities?
Yes
No
If yes, please specify:
Have you previously undergone electrolysis treatment?
Yes
No
If yes, please provide details:
I understand the potential risks and benefits of electrolysis treatment, including possible side effects such as redness, swelling, and discomfort. I have had the opportunity to ask questions and have received satisfactory answers.
I Agree
I Do Not Agree
I consent to the treatment and confirm that I am over the age of 18 or have parental consent.
*
I Consent
I Do Not Consent
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: