Electrolysis Pretreatment Questionnaire

Electrolysis Pretreatment Questionnaire
Name*

First NameLast Name
Appointment Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of birth*
Email*
Who referred you? (name)*
Do you have a history of unusual scarring?*

YesNo
Are you under the care of a physician?*

YesNo
If yes, why?
Are you pregnant?*

YesNo
Do you have any of the following? Please check all that apply.*

DiabeticHepatitisPacemakerAllergiesNone of the above
Please check if you are allergic to any of the following:*

Local anesthesiaRubbing alcoholWitch HazelLatexNone of the above
Hair removal methods used previously:*
Have you had electrolysis treatment before?*

YesNo
If yes, when?
I am aware that:
- Electrolysis does involve a series of treatments which can be completed in approximately 1-3 years depending on what is causing the hair growth and what means of temporary hair removal has been used.
- Persons that have been tweezing an area for years will require more treatments in that area because the hairs will be coarse and distorted.
- Hairs that have not been tweezed will require less treatments due to their soft texture and shallow roots.
- It is important to stay on a regular schedule due to the cycle in which hair grows (between 2-4 weeks).
- After a series of consistent treatments between 4-6 months, the regrowth will become less and more time will be scheduled between office visits.
INFORMED CONSENT FOR

ELECTROLYSIS HAIR TREATMENT

Electrolysis is a medically approved method of permanent hair removal. Only actively growing hairs and follicles are affected and several treatments are necessary.

The treatments, expectations from the treatment, and post treatment care have been explained to me and my questions regarding the treatment have been answered to my satisfaction.

I understand that the treatment works on actively growing hairs and follicles and not on any that are dormant. For this reason, it requires several sessions to complete a course of treatment.I am aware of the following possible risks associated with this treatment including, but not limited to:
- Infection - Skin infections can occur any time the skin is broken.
- Discomfort- Some discomfort may be experienced during this treatment. Topical anesthesia may be used if necessary.
- Pigment changes (skin color)-During the healing process, the treated areas may become darker or lighter than the surrounding skin. This is usually temporary but, on rare occasions, may be permanent.
I certify that I have read this entire consent form and that all of my questions have been answered, and I understand and agree to the information provided above. I consent to and authorize Dolce Organic Salon, Med Spa & Salt Room to perform Electrolysis.
By typing my name below, I acknowledge and agree with this document.*
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