HAIR REMOVAL MEDICAL HISTORY FORM
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Age
*
Birthdate
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Male
Female
How did you hear about us?
*
Please Select
Facebook
Website
Instagram
Friend or family
Drove by
Business partner/Carla
Other
If referred by a friend leave their name here:
Areas of concern: (Areas you would like to treat)
*
Treatment area hair color:
*
Please Select
Dark/black/dark brown
Gray/white/dishwater blonde
Red
Salt & pepper
Approximate Age this hair growth started:
*
Hair Growth speed:
Please Select
Abrupt
Slow
Normal/supposed to be there
Hair density:
*
Please Select
Scattered
Concentrated
Hair type:
*
Please Select
Coarse
Long/thin
Short/peach fuzz
Skin type:
*
Please Select
Dry
Moist
Oily
Combination
Family members with hair growth :
Mother
Sister(s)
Grandma
Previous temporary treatment methods used in the area: (select all that apply)
*
Plucking
Shaving
Trimming
Waxing
Sugaring
Creams
Threading
Bleaching
Sanding
Previous electrolysis?
*
Yes
No
Which body area was treated?
Establishment
Previous Laser?
*
Yes
No
Which body area was treated?
Establishment
Female History
Number of children
Number of miscarriages
Pregnant
Yes
No
Infertility
Yes
No
Regular menstrual Cycle
Yes
No
Perimenoposal
Yes
No
Post Menopause
Yes
No
Hysterectomy
Uterus only
Uterus / ovaries
Allergies
*
Topical products
Cain Family
Aloe
Lavender
Chamomile
Metals
None
Other
Medical Conditions:
*
Diabetes / Healing issues
HSV1 Cold sores
HVS2 Warts
Blood diseases (Hep A, B, C, HIV)
STD
Polycystic ovarian system (PCOS)
Bleeding disorder
Bruising or Scar easily
Dizziness/Fainting
Cardiovascular
Pacemaker
Thyroid Condition
Depression
Anxiety
Eating Disorders
Diarrhea
None
Other
Metal in body
*
Yes
No
Location of metal in body
Medications:
*
Birth control
Hormones
Steroids
Antidepressants
Antianxiety
Anti-Seizure
Blood thinners
Blood pressure
Thyroid
Antibiotics
Retin-A
Accutane
Herbs (St John’s wart)
Botox
Fillers
None
Other
Skin observations:
*
Scarring
Pitting
Keloids
Acne
Pustules
Comedones (black heads)
Eczema
Rash
Dermatitis
Moles
Hypopigmentation
Hyperpigmentation
Telangiectasias
Growths
Rosacea
Skin cancer
Psoriasis
None
Other
Ethnic Background
*
Caucasian
Hispanic
Asian
African American
Mediterranean
Middle eastern
Indian
Other
When exposed to the sun… Are you the person who?
*
Always burn / Never tan
Always burn then tan
Sometimes Burn / Mostly tan
Always tan / Never burn
Have you used a tanning bed in the last two weeks
*
Yes
No
Have you used a chemical sun tanning lotion in the last two weeks
*
Yes
No
Are you planning a vacation in the sun in the next two weeks
*
Yes
No
Mark in agreement to the following terms and conditions.
*
I certify and attest all of the information I have provided to Hairfree Solutions is true to the best of my knowledge.
I understand hair removal clinical results may vary with individual factors including: skin types, hair colors, hair types, patient compliance with pre/post treatment instructions, my pain tolerance, heredity, hormones, medical conditions and medications.
I understand a series of treatments will be necessary to achieve permanency and the success of treatment is dependent on my individual commitment to the treatment schedule.
I confirm I am not pregnant and I have not used Accutane within the last 6 months, I do not have a pacemaker or internal defibrillator. I have disclosed all of my medical history and medication use to Hairfree Solutions and will inform the company of any future health or medication changes.
I understand prior to my treatment it is MANDATORY I come showered and clean to ensure my body, hair, and face are free of dirt, sweat, lotions and makeup.
Due to the nature of treatments and insurance liabilities children are not permitted.
I will honor Hairfree Solutions cancellation policy and agree to pay 50% of all scheduled appointments if a 24 hour notice is not given. I am aware of Hairfree Solutions fee structure. I understand packages are non refundable.
I consent to photographs and authorize their use for the purposes of medical audit, education, and promotion.
I have received and read the pre/post treatment instructions and fully understand the content.
I have been fully informed of the nature and purpose of these procedures, expected outcomes, possible complications, and I understand no guarantee can be given as to the final results obtained. I am fully aware of the conditions of these cosmetic procedures and my decision to proceed is based solely off my expressed desire to do so. I give consent to treatment to Hairfree Solutions LLC
Date
*
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Month
-
Day
Year
Date
Signature
*
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