Electrolysis Consultation Form

ANJA GOSHA

Office No 4, Third Floor

Cambrian Buildings

West Bute Street CF105FL

anjagosha@gmail.com

www.anjagosha.com

07841433508
Electrolysis Consultation Form

Please complete all fields.
Customer name*

First NameLast Name
Address*

Street Address

Street Address Line 2

City

Postcode
In case of emergency please contact*
Please provide full name and phone number
Your family doctor name and address *
Please provide full name and phone number
Date of birth*

MonthDayYear
Date
What area would you like to treat? *
Please explain in detail.
What is your skin condition? *
In the treatment area
Do you have:*

Any heart conditions such as angina or blood pressure problems?Prosthetic heart valve/ congenital heart disease?A peacemaker in situ?Epilepsy?Haemophilia or blood clotting disorders?Diabetes?Any skin problems such as psoriasis or eczema/dermatitis?Any lumpy raised scars(hypertrophic/ keloid scars)?Hormonal disorder including PCOS?Neurological disorder that causes loss of sensation?Cold sores?
Do you take any prescribed medication? For example anticoagulants to prevent blood cloths?*
Please explain in detail.
Have you ever had anaphylactic reaction( requiring hospitalisation and/ or adrenaline)?*

YesNo
If yes what was the trigger?
Please explain in detail.
Do you have any known allergies to plasters/creams/metals/iodine/shellfish/latex/foodstuff/other?*

YesNo
If yes what is it?
Please explain in detail.
Do you take any medication that affects your immune system such as “immunocomppresive treatments” (example cancer treatment such as chemotherapy) high dose of steroids or treatment used for inflammatory conditions? *
Please explain in detail.
Have you taken oral or topical steroids in the last 6 months? *
Please explain in detail.
Have you been prescribed treatment with Retinoids (Accutane) in the last 12 months? *
Please explain in detail, including dose.
If yes what's the name and dose?
Please explain in detail.
Have you used acid based products within the last 1-3 weeks?*
Please explain in detail.
Have you had any aesthetic treatment such a chemical peels, ablative laser, resurfacing, anti-agening, dermabrasion, in the last 6 months?*
Please explain in detail.
Have you had undergone facial surgery in the last 12 months?*
Please explain in detail.
Do you have any metal implants?*
Please explain in detail.
Have you received chemo/radio or photodynamic su4gery in the last 6 months?*
Please explain in detail.
Are you pregnant or breastfeeding?*

YesNo
Are you prone to” fainting attacks”?*

YesNo
If yes, please state trigger.
Please explain in detail.
Have you applied a topical anaesthetic in advance of receiving special procedure? If yes please provide details*
Please explain in detail.
Is there anything else you would like to add before treatment can commence? *
Please explain in detail.
How did you hear about me?
Google, social media etc?
What to expect:

Our hair is constantly changing from several factors that make us who we are; it's in our DNA. It is this diversity that makes proper hair removal through electrolysis a process. As our body reacts to different situations such as hormones, medications, weight and even our genes, our hair pattern changes and may activate dormant hair follicles. The complex nature of hair growth controls the number of sessions required to reach your personal preference for hair removal. Generally, electrolysis results are noticeable within three months and can take up to 24 months for the complexion. The session can be booked from 15min to 2 hours, and the treatment plan will be explained and rebooked after the first session. Each individual has a different tolerance level, and that is taken into consideration by an electrologist. To help manage discomfort, topical creams and sprays are recommended. Please kindly notice Anja can not recommend or provide any information about those. After treatment, it is common to experience redness or swelling, both of which are usually short-lived. Those are both natural reactions from the stimulus applied to the follicle and can be eased with the use of cold aloe vera or witch hazel gel. To prevent any other response, you must inform Anja of any changes in medical condition, medication, supplements, lotions oils etc.
Few points to remember:

-Shaving five to seven days before a treatment appointment, bleaching and other temporary hair removal treatments around two to three weeks before an appointment are allowed (some people may be able to shorten these times).
-Once electrolysis treatments have begun however other treatments should be discontinued. Waxing, plucking etc will slow down electrolysis treatment and will make it more expensive.
Shaving is the only preferred method of hair removal during electrolysis treatment.

-Well-hydrated skin can help the treatment be more effective so we recommend that the client drinks an ample amount of water in the week prior to their appointment.
-No alcohol-based products should be used in the treatment area on the day.
-If the pain factor is a worry for you take two Panadol tablets one hour prior to the appointment but don’t exceed the dosage instructions – the thought may be worse than the deed.
-Please wear freshly laundered, loose clothes for your appointments.
1. I understand that the frequency and longevity of treatments are determined solely by my body’s natural hair growth and therefore not predetermined.

2. I understand that possible side effects may include, but are not limited to:

-inflammation of the hair follicle

-oedema (swelling)

-purpura (bruising)

-redness directly after treatment

-change in pigmentation in the treated area

-small blisters and pinpoint bleeding (possible scarring if these are aggravated)

3. Results rely on the accuracy of the information I have provided regarding my medical history and my adherence to proper before and aftercare.

4. Treatment is not guaranteed due to the risk of complications, both known and unknown to the technician and myself
Consent Form for Electrolysis Hair Removal TreatmentI, have read, understood, and accept the terms and conditions regarding the electrolysis hair removal treatment provided by Anja Gosha.I hereby consent and authorize Anna to perform electrolysis hair removal treatments on me. I also consent to any related services that may be necessary before and after the treatment.I understand that photographic evidence is essential for both treatment monitoring and insurance purposes. I agree to have pictures taken of the treatment area before and after the procedure. These photographs will be stored securely and used solely for the purposes of my treatment documentation and insurance requirements.I acknowledge that I have had the opportunity to ask questions about the treatment and have received satisfactory answers. I am aware of the potential risks and benefits associated with the procedure and agree to proceed with the treatment.*

Yes

My Products

Witch Hazel Big Tube 200ml Product Image

Witch Hazel Big Tube 200mlAn excellent cooling, soothing gel which is quickly absorbed into the skinRecommended for application after any form of hair removal including electrolysis and laser.Also suitable after sunbathing or general moisturising of the skin.This is 200ml tube✓ Contains 95% liquid extract of Aloe Vera✓ Has a refreshing lemon grass fragrance

£15.00 Quantity

Aloe Vera Small Tube 35mlA sample version of aloe vera gel. Size: 35ml

£5.00

I do not require any, thank you

£ Free

Total

£0.00

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