Client Intake Form

Today's Date*

MonthDayYear
Date
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Phone Number*
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*

ChinLipBrowsNeckSideburnsCheeksBeard CleanupArmsLegsUnderarmsStomachChestBreastsShouldersBackHandsFeet
What area is priority to treat at this time?*
Previous methods of hair removal*

ElectrolysisShavingTweezingWaxing/sugaringLaserThreadingDepilatories (Nair)Bleaching CreamTrimmingOther
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:*

AcneWhiteheadsBlackheadsCanker SoresCarcinomaFever BlistersCold SoresPsoriasisDermatitisDiabetesThyroid DisorderPCOSEczemaCongenital Adrenal HyperplasiaHemophiliaFolliculitisEpilepsyHepatitis (A,B,C)HerpesKeloid ScarsMolesWartsHyperpigmentationHypopigmentationVitiligoFacial ScarsSkin TumorsNoneOther
Implants*

PacemakerCochlear ImplantsMetal Implants/pinsDental ImplantsIUDNoneOther
Are you pregnant or planning to become pregnant?*

YesNo
Menstrual History*

Hormone ImbalanceIrregular PeriodsMenopause (current)Post menopauseHysterectomyNone
Allergy Sensitivity*

Seabreeze Antiseptic70% alcoholAloe Vera GelNitrile glovesNone of the above
Current Medications*

Oral ContaceptivesCortisoneHormonesHigh-blood pressureAnti-coagulantsDilantin (seizure drug)Anti InflamitoriesNone of the above
Do you have an unusual skin condition, if so please explain
Client Signature *

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Parent/guardian signature (if client is under 18 years old)

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Relationship to client (if client is under 18)
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