CLIENT HISTORY FORM

CLIENT HISTORY FORM

Please read the information below and provide your consent for the electrolysis treatment.
PERSONAL INFORMATION
Full Name*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
How would you like Eclairage Spa to contact you for appointment reminders, special offers, etc?*

PhoneTextEmail
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Areas to be treated:*

FaceUnderarmsBikini AreaNoseArmsChest/BreastBack Upper/Center/LowerUpper LipEye browsHair lineEarsChinLeg/Lower legFeet/ToesAbdomen/StomachUpper/Inner ThighsNoseOther
If yes, please specify:
PREVIOUS METHODS OF HAIR REMOVAL
Have you previously undergone electrolysis treatment?*

YesNo
Select ALL methods that you have used, write which areas of the body, add date when last used and how many*

ShavingWaxing/Sugaring/ThreadingLaserTweezingElectrolysisCutting/ClippingDepilatoriesNo methods usedOther
For each method selected above, please list the areas of the body, add date when last used and how many years total.
Skin reactions to previous hair removal methods (select all that apply)*

RednessPimplesInfectionsIngrown hairSwellingNo reactionPigmentationOther
Describe any of the skin reactions in detail so we can best set up your healing-based treatment plan.
GENERAL HEALTH QUESTIONS
Current Medications
Reasons for Current Medications
Past Medications
Reasons for Past Medications
Select all conditions, past and present that apply

AcneAllergy to LatexBreathing ChallengesAllergy to MedalDiabetesBlood ClotsPigment ProblemsHepatitisHIVKeloidsMetal ImplantsPacemakerCurrent PregnancyAllergy to AspirinCardiovascular DiseaseCancerCold SoresHigh Blood PressureSkin TagsMolesHerpesTBHealing ProblemsBody PiercingsWartsOther Conditions or Allergies (Explain Below)
Provide any additional medical information that would be important for us to know
Date of last complete physical*

MonthDayYear
Date
ACKNOWLEDGMENT OF INFORMATION
I understand health history information is important to Eclairage Spa in order to provide me with safe and effective electrolysis healing-based treatments. I acknowledge all information given by me today in completing this form is accurate to the best of my knowledge and I agree to update my health history record whenever there are changes.
Initials*

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I understand that a series of treatments over usually 12-24 months (but possibly longer) is necessary to achieve permanent hair removal based on my previous temporary methods of hair removal, the science of electrology, and my individual physiological factors.
Initials*

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There is a post-treatment healing process, and possible risks related to treatment that will be discussed in detail with me before my treatment starts. I agree to follow all aftercare instructions and to notify Eclairage Spa of any concerns or difficulty in healing. Further, I will not hold Eclairage Spa liable for any omissions or post-treatment reactions.
Initials*

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I understand that any further questions I may have regarding the treatment will be answered before or at my first session.
Initials*

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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 AgreeI Do Not Agree
I consent to the treatment and confirm that I am over the age of 18 or have parental consent.*

I ConsentI Do Not Consent
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Date

MonthDayYear
Date
Should be Empty:

CLIENT HISTORY FORM

PERSONAL INFORMATION

PREVIOUS METHODS OF HAIR REMOVAL

GENERAL HEALTH QUESTIONS

ACKNOWLEDGMENT OF INFORMATION