Client Health Information Intake Form

*If this is your first appointment or you have not been in for an appointment in over a year, please save time and fill out the "CLIENT HEALTH AND CONTACT FORM" on Fresha*
ElectrolysisNW

Client Intake Form.
Name*

First nameLast namePreferred name
E-mail*
Phone Number*
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Gender:
F
M
TF
TM
Non Binary
Prefer Not to Answer
Birth Date

MonthDayYear
Date
Medications :
:
Are you under a Doctor's care? Yes
Physician"s name;
Allergies
Diabetes
Carcinoma
Circulatory disorder
Defibrillator
Epilepsy
Heart
Hepatitis
Herpes Simplex
Pacemaker
Metal Implant
Xray Treatment
Birth Control
Menopause
Hysterectomy
Irregular Periods
Pregnant
Comments on medical issues
Are you on any of these skincare medications?

AHA/Glycolic acid.Retin A/Renova.Accutane.Differin.
Have you had previous laser and or electrolysis? If so, please explain.*

YesNo
Please provide details
What areas are you interested in having treated?
Are you waxing, tweezing, shaving, or doing any dipilitories on the area you want treated? If yes, please specify what you are doing and how often hair is being removed.*

YesNo
Please provide details*
Have you had any Botox, Dermal Fillers, skin resurfacing, or chemical peels in the past 6weeks?*

YesNo
Please provide details
Do you have any other medical condition, injury or anything else we should be aware of that we have not mentioned?*

YesNo
Please provide details
CONSENT FORM
Electrolysis treatments are a form of electrical epilation with a minimal amount of current being delivered to the root of the hair to destroy it through a variety of modalities. All Modalities will treat only the hair follicle, making this a non-invasive and direct way to target unwanted hair.ONLY ACTIVELY growing hairs and follicles can be treated by an electrologist and multiple sessions will be necessary.

Galvanic Electrolysis: Galvanic Electrolysis is the oldest type of electrolysis. The Direct Current used is extremely effective but very slow. It creates a chemical change in the follicle to disable the root.

Thermolysis Electrolysis: Thermolysis uses high frequency or AC current to heat the hair follicle.

Blend Electrolysis: combines both Galvanic and Thermolysis in one treatment.
I understand that the treatment is not guaranteed due to risks of complications both known and unknown to myself and the electrologist.*

Yes
I understand that results are reliant on the accuracy of Information I have provided regarding my medical history and my adherence to proper before and after care.*

Yes
I understand that possible side effects may Include but are not limited to: Inflammation to the hair follicle. Edema (Swelling) Purpura (Bruising). Redness after treatment. Change in Pigmentation. Small Blisters and or pinpoint bleeding (possible scarring if these are aggravated.*

Yes
I understand that the frequency and longevity of treatments is determined solely on my body's natural hair growth and therefore not predetermined by the Electrologist.*

Yes
I understand and comply with the Practice's 24 hour cancellation policy, that if I am LATE or a NO CALL NO SHOW I may be charged the entirety of my appointment and will pre pay for the next appointment. Payment for treatment is non refundable..*

Yes
I Acknowledge that I have read, understood and accepted the terms above regarding Electrolysis Hair removal. I hereby consent to and authorize the electrologist(s) to preform Elctrolysis Hair Removal treatments related before and after treatment services on me.*

Yes
I acknowledge that:

I am over 18I am the legal guardian of the above:
Signature

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What to expect.

A common experience is redness, swelling and/or bruising. This will disappear within a few hours.These are natural reactions to the stimulation applied to the follicle.
In order to prevent any additional reaction, it is critical that you inform us of any medical conditions, medications, supplements, lotions and oils.

Post Treatments
Home care is vital for positive results.
DO NOT touch treated area with hands
Clean with an astringent 2-3 times a day for 3 days.
No swimming, hot tub or jacuzzi for 48 hours.
Apply Tissue Repair Cream morning and night.
Avoid sun exposure. Apply min spf 15 sunblock daily.
Do not apply makeup for 24 hours.
DO NOT scratch or pick at scabs, as this will result in scarring.
Underarms- DO NOT use deodorant for 48 hours. Astringent, natural deodorant, or a vinegar mix are great alternatives.
DO NOT tweeze or wax treated areas. You may shave or trim with scissors.
After your treatment the area is clean and free of bacteria.
- Keep it clean to avoid infection.
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