Electrolysis Assessment & Aftercare

Electrolysis Assessment & Aftercare
Name*

First NameLast Name
Date of Birth *

DayMonthYear
Date
Address*

Address Line 1

Address Line 2

Town/VillageCounty

Post Code
Phone Number*
Email*
example@example.com
Emergency Contact
Emergency Contact Telephone Number
How did you hear about me?*

FacebookInstagramOnline SearchReferral
If referred, by who?
Your Medical History
Are you currently under the care of a physician?*

YESNO
Have you experiences any of these health conditions in the past or present?*

Cancer/ Systemic diseaseHigh Blood PressureDiabetesHeart ConditionsStrokeArthritisHepatitisKidney DisorderLiver DisorderDigestive ProblemsMigraineAuto-immune DisorderAsthmaEpilepsy/SeizuresCold sores/blistersHIV/AIDSLupusDepression/AnxietyHeadaches/ MigrainesEczemaPsoriasisDermatitisHistory of AnaphylaxisDiabetesHaemophiliaBlood DisordersRecent Virus (within the last 2-4 weeks)History of Skin CancerAre you Pregnant or Nursing/ Receiving Fertility TreatmentHormonal Imbalance (PCOS/Endometerosis/Fibroids/Cysts)Taken Acctutane in the last 6 monthsGlucomaChest Pain/Shortness of BreathAllergiesHistory of Keloid ScarringOther
Are you taking prescribed medication including the Contaceptive Pill/ HRT – State brand
Are you taking any non prescription medication including Vitamin supplements, St Johns Wort, Probiotics etc?
Do you have any allergies?*

AsprinLatexFruitsShellfishLidocaineFragrance/Essential OilsNutsDairySunscreenPollenOther
Have you received botox or fillers in the treatment area within the last 2 weeks?
Have you had any form of Semi Permanent Makeup, If so when was your last treatment?
What areas are you seeking hair removal for?
Have you had any previous hair removal treatments? If yes please give a brief outline of the treatments you have had and when you had them.
Have you suffered any skin damage or reaction from previous hair removal treatments? If yes please describe.
Which best describes your skin?

I. Pale white skin, blue/green eyes, blond/red hair - Always burns, does not tan.II. Fair skin, blue eyes - Burns easily, tans poorly.III. Darker white skin - Tans after initial burn.IV. Light brown skin - Burns minimally, tans easily.V. Brown skin - Rarely burns, tans darkly easily.VI. Dark brown or black skin - Never burns, always tans darkly.
How would you describe your skin?

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily T-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
Do you experience routine breakouts or acne?

YESNO
Have you been diagnosed with eczema, psoriasis or rosacea?

YESNO
Have you used any of these facial hair removal methods in the last 14 days?

Waxing/sugaringThreadingLaser/ElectrolysisDepilatory CreamFacial Bleaching
Have you had any of the following treatments in the last 6 weeks?

Skin PeelMicrodermabrasionMicro-needling/ MesotherapySunbedor Sun Exposure
Do you currently use:

Use Retinol in skincareRetin-A (prescribed)Prescribed topical cream such as Duac, Steroid cream, Anti- Histamine
Please specify which product or type, if you answered YES to the question above.
Declarations & Acknowledgements

Appointments and Cancellations

I acknowledge that I must adhere to Charlotte Rye Aesthetics policies.

I understand that cancellations must be made with at least 48 hours notice.

I acknowledge that ANY No-Show will result in the loss of a single treatment from a pre paid course or 100% of the total service cost.

I understand that if I arrive late for my appointment it may be subject to cancellation or to a reduced treatment time and I will be responsible in accordance with the “No-Show” policy.
Aftercare for electrolysis

First and foremost, please ensure that you keep the treated area meticulously clean and dry for the first 48 hours post treatment.

It is important to take extra care of the treated area, especially within the first 48 hours* of treatment. This will give the skin a chance to settle, allow the heat reaction in the skin to return to normal and prevent infection of the treated open follicles.

After treatment you may experience

Redness, swelling and sensitivity of the skin in the area which has been treated up to 48 hours*

The treated area and surrounding skin may feel hot for up to 48 hours*

Pin dot crusting or small scabs may appear within the treated area.

The skin may itch as the healing process takes place.

Points to remember for 48 hours* after treatment

Skincare

Sterex Witch Hazel and Aloe Vera gel should be applied liberally using clean, damp cotton wool immediately after electrolysis to soothe, calm redness and prevent infection.

To prevent irritation and the spread of infection, do not pick spots or small blood scabs which may appear a couple of days after treatment and depending on the skin, may take between 3–21 days to heal.

Fine blood scabs are a normal post reaction response to the treatment, especially in the initial stages of having electrolysis. The fine blood scabs develop by the dry cauterized blood in the base of the follicle rising up through the follicle. Do not pick the area at all.

For clients who have long hair, to reduce the risk of infected follicles, keep hair tied back off the face.

Avoid: Touching the treated area and do not pick any scabs that may form

Avoid: Self tans or fake tans as these can cause irritation to the skin, also avoid perfumes, and perfumed body lotions

Avoid: Direct sunlight, or sun bed treatment. If you must go out in the sun, use a high protection factor sunscreen of at least SPF 30 to avoid hyper pigmentation, especially on darker skin tones, Black and Asian skin. Re apply in the middle of the day. UVA and UVB can cause pigmentation marks to appear on the treated area and wearing our SPF 30 will help to reduce this quicker, developing an even skin tone faster.

Avoid: Saunas, solaria, sun beds, jacuzzis and steam treatments as these can also cause pigmentation to develop for at least 48 hours.

Avoid: Hot baths, showers for 48 hours

Avoid: Swimming for 48 hours

Avoid: Applying make-up to the treated area for 48 hours.

Avoid: Applying soap or perfumed products to the treated area for 48 hours.

Avoid: Activities for 48 hours that stimulate blood flow following treatment ie Cardiovascular exercise.

Avoid: Wearing tight or restricted clothing over treated body areas for 48 hours.

Points to remember whilst having electrolysis

Cleansing

When washing or cleansing use gentle un perfumed cream cleanser or facial wash, never use soap on the treated area as this will further dry the skin. Gently pat the area dry to avoid dislodging any fine scabs or crusts

Bleaching

If you would like to bleach the downy hair growth between treatments, do not apply bleach for at least 48 hours after electrolysis.

Re-growth

Do not pluck, tweeze, thread or remove hair with wax or depilatory cream remover between electrolysis treatments, as this will interrupt the hair growth cycle. It is safer to simply trim any noticeable unwanted hair with scissors

I AM NOT RESPONSIBLE FOR CLIENT’S SKIN CARE POST ELECTROLYSIS TREATMENT

* NB: For most people, after-effects of the treatment normally clear within 48 hours. However, everyone is different, so please do not be alarmed if it takes a bit longer. If in doubt, please contact me.
agreement*

I have read and understand the post treatment aftercare.
Consent & Agreement

I consent (to the best of my knowledge) that the answers I have given are correct and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments.

I release Charlotte Rye of any liability associated with any injuries and /or current and future conditions resulting from the skincare procedures or products.
Date*

DayMonthYear
Date
Signature*

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Treatment Notes
Should be Empty:

Electrolysis Assessment & Aftercare

Your Medical History

Declarations & Acknowledgements

Appointments and Cancellations

Aftercare for electrolysis

After treatment you may experience

Points to remember for 48 hours* after treatment

Skincare

Points to remember whilst having electrolysis

Cleansing

Bleaching

Re-growth

I AM NOT RESPONSIBLE FOR CLIENT’S SKIN CARE POST ELECTROLYSIS TREATMENT

Consent & Agreement