Client Intake Form

Today's Date

MonthDayYear
Date
Client's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about Santa Cruz Electrolysis?
Desired Treatment Areas
What area is priority to treat at this time?
Previous methods of hair removal

Other
How long and how often have you used these methods?
Describe any reactions your skin has had to previous hair removal methods
Do you have any of the following conditions? If yes, please select them:

Other
Implants

Other
Are you pregnant or planning to become pregnant?
Menstrual History
Allergy Sensitivity
Current Medications
Do you have an unusual skin condition, if so please explain
Client Signature
Parent/guardian signature (if client is under 18 years old)
Relationship to client (if client is under 18)
Should be Empty: