Client Health History Form

Rubiology
237 W. 4th St.
Claremont, CA 91711
phone or text: 909.624.8617
https://www.therubiology.com/
rubiologyelectrology@gmail.com
IG rubiology__
Client Health History Assessment

Collecting medical and personal information is crucial for providing safe and effective electrolysis treatments at Rubiology
Client Information

Here at Rubiology, we have all our employees sign a Non-Disclosure Agreement (NDA) and a Rubiology Confidentiality Agreement. All personal information, documents and personal files you provide are kept confidential & securely in your guest profile and will be used solely for the purpose of ensuring your safety and the effectiveness of your treatments.
Guest Name

Legal First NameLegal Last Name
Preferred Name:
Gender Identified as:
Are you above the age of 18?
Date of Birth:

MonthDayYear
Client Date of Birth
Today's Date:

MonthDayYear
Date
Company Email
example@example.com
Guest Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guest Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guest Email
example@example.com
Emergency Contact Information

In the unlikely event of an emergency, having your emergency contact information allows us to quickly reach out to someone who can assist.
Emergency Contact Name:
Name of person to contact incase of emergency
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Hair Removal Information

Different skin types and sensitivities respond differently to electrolysis. By understanding your skin type and previous reactions from past treatments, we can adjust the equipment settings and techniques to minimize discomfort and maximize effectiveness.
Please Check all areas you wish to be treated
Head:

Other
Body:

Other
Limbs:

Other
Are you seeking treatment on or near a mole (raised or flat) or pigmented lesion?
Mole Treatment Clearance Acknowledgment (California Requirement)

Before we can perform electrolysis on or near any mole (raised or flat), we require written medical clearance.
By checking below, I understand and agree that:
- Any mole or pigmented lesion must be evaluated and cleared by a licensed physician (MD or DO) prior to treatment
- The clearance must confirm that the area is benign and safe for electrolysis
- Documentation from a Physician Assistant (P.A.) or Nurse Practitioner (N.P.) is not sufficient for this service
- I am responsible for obtaining and providing this documentation before my appointment
- If proper clearance is not received, treatment on the mole will not be performed, and my appointment may need to be modified or rescheduled
Previous Hair Removal Methods
What hair removal methods do you most frequently use? {select all that apply}

Other
How often would you use this method?

Other
Have you ever had dermabrasion done before?
Please select yes or no
Last Dermabrasion Treatment:

MonthDayYear
Date
Skin History
Skin Health

Please be as detailed as possible.
Have you ever had acne?
If you selected YES, how would you describe your acne?
Are you seeing the results you’d like from your current skincare routine?
Please list what you’re using and how you use each product.
Skin Reactions
Skin reactions/irritation to any previous hair removal methods? {select all that apply}

Other
Previous Electrolysis Treatments
Have you ever had Electrolysis before?
Please select yes or no
If yes, pleases provide your Electrologist's Name and/or Location:
Date of last treatment:

MonthDayYear
Date
Treatment areas:
Please list areas worked on
Total # of treatments:
Modality: {select all that apply}
Medical History

Understanding your medical history helps us identify any conditions that might affect your treatment, such as skin conditions, allergies, or circulatory issues. This ensures we can tailor the procedure to your specific needs and avoid any adverse reactions.
Medications

Some medications can affect skin sensitivity and healing. Knowing what medications you are taking allows us to adjust the treatment accordingly and ensure your safety.
List All Medications & Vitamins You are Currently Taking:
Allergies

Information about any allergies, particularly to metals or topical products, helps us avoid using any substances that could cause an allergic reaction during the treatment.
List All Allergies:
Additional Comments
Past & Present Health Conditions
Skin Conditions: {select all that apply}

Other
Health Conditions: {select all that apply}

Other
Body and Skin Modifications and/or Implants: {select all that apply}

Other
Menstrual Health
Are you pregnant or planning to become pregnant:
Please select yes or no
Do you get your period:
Please select yes or no
If yes, is it regular:
Please select yes or no
Gender-Affirming Journey
Are you preparing for sex reassignment surgery
Please select yes or no
Physician’s Name:
Physician's name for planned surgery
Physician's Phone Number:
Please provide your physicians phone number
Physician’s Location:
Please provide physicians location
May we contact your physician to discuss your treatment plan:
Please select yes or no
Additional Information
How did you hear about us?

Other
Photo Consent for Progress Tracking & Media Release
To provide the best service and monitor your progress, we may take photos during your initial visit and throughout your treatment. These photos will be kept confidential and are solely for tracking your treatment progress. They will remain securely stored in your customer profile and will never be shared without your explicit consent. If you choose to allow us to use your photos or videos for social media or marketing purposes, you will be informed and asked to sign a separate media release form. ***Photos of private areas are never taken or used under any circumstances.***
Do we have permission to document your hair removal progress in photos and/or videos to use as promotional material for our company’s print and/or digital publications?
If at any time this answer changes, please update Rubiology team members of your knew preference
Photographs:
Please select yes or no
Video:
Please select yes or no
Additional Comments & Questions:
Client Acknowledgement of Information
I understand health history information is important to my Electrologist in order to provide me with safe and effective electrology treatments. I acknowledge all information given by me is accurate to the best of my knowledge, and I agree to update my health history assessment whenever there are changes.
Initials
I understand that electrolysis requires a series of treatments in order to achieve permanent hair removal and my progress will be impacted by my personal hair growth rate, the science of electrology, and my individual physiological factors.
Initials
I have been advised of the pre and post-treatment care, the healing process and the possible risks related to treatment. I agree to follow all aftercare instructions and to notify my Electrologist of any concerns or difficulty in healing.
Initials
I understand my electrologist has the right to refuse treatment if it is not beneficial to my health or skincare due to know nor unknown health conditions I may have.
Initials
Guest Name

First NameLast Name
Guest Signature
Date of Guests Signature:

MonthDayYear
Date
Parent/Guardian's Name:
Parent’s Name
Parent/Guardian's Signature:
Date of Parent/Guardian's Signature:

MonthDayYear
Date
THANK YOU FOR YOUR BUSINESS

Rubiology Team
Should be Empty:

Client Health History Assessment

Client Information

Emergency Contact Information

Hair Removal Information

Please Check all areas you wish to be treated

Mole Treatment Clearance Acknowledgment (California Requirement)

Previous Hair Removal Methods

Skin History

Skin Health

Skin Reactions

Previous Electrolysis Treatments

Medical History

Medications

Allergies

Past & Present Health Conditions

Menstrual Health

Gender-Affirming Journey

Additional Information

Photo Consent for Progress Tracking & Media Release

Client Acknowledgement of Information

THANK YOU FOR YOUR BUSINESS