Electrolysis questionnare

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Post CodeCountry

E-mail*

Phone Number*

Area CodePhone Number

EMERGENCY Contact Phone Number*

Name and RelationPhone Number

Referred By:

Date of Birth*

DayMonthYear

Have you had previous electrolysis? If so, please explain.*

YesNo

Please provide details

Have you had laser hair removal done before on areas you seek Electrolysis treatment? If so, please explain.

YesNo

Please provide details

What areas of the face or body are you looking to have hair removed?

Please provide details

Do you have any Hormonal imbalances? If so please explain.*

YesNo

Please provide details

When was the last time you were exposed to the sun ?*

This weekPast 2 weeksNo exposure in past Month

Please provide details

Are you using any retinols/ hydrocortisone/ Retin-A/ bleaching cream or any prescription Topicals on skin? If so please, explain.*

YesNo

Please provide details

Any cosmetic tattoos/ permanant makeup in area being treated? *

YesNo

Have you taken any antibiotics in the last 14 days?*

YesNo

Please provide details

Are you taking any prescribed medications or dietary supplementation?*

YesNo

Please provide details

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*

Are you pregnant or breastfeeding?*

YesNo

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

YesNo

Please provide details

History of HSV (Cold sores/ Fever Blisters)

YesNo

Have you been diagnosed with HIV?

YesNo

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 rood of the hair to destroy it through a variety of modalities. All Modalities will treat only the offending hair follicle, making this a non-invasive and more direct route to target unwanted hair.ONLY ACTIVELY growing hairs and follicles can be treated by and electrologist and multiple sessions will be necessary.

Electrolysis Methods:
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 shortwave radio frequency or AC current. Thermolysis causes the water molecules by your hair to rapidly vibrate, which produces heat. When enough heat is created, thermolysis damages the cells that cause hair growth.
Blend Electrolysis: True to its name, blend combines both Galvanic and Thermolysis in one treatment. If one type of electrolysis doesn't kill your unwanted hair the other method will.

HOLISTIC GLOW ELECTROLOGY USES THE METHOD OF THERMOLYSIS FOR HAIR REMOVAL. ANOTHER NAME FOR IT IS FLASH

What to expect
A common experience is having pin point scabs in treated area, redness, swelling, bruising or all of the above. These are all natural reactions from the stimulation applied to follicle. It can be eased with the use of an ice pack and after treatment gel 2-3 times daily. In order to prevent any additional reaction, it is critical that you inform us of any medical conditons, medications, supplements, lotions and oils.

Post Treatments
Avoid Direct Sunlight
Avoid exercise and or anything that may cause sweating within 24hours.
Keep area washed and clean
Use ice-pack if necessary
After Treatment Gel is recommended 2-3 times daily
DO NOT pick, rub or scratch area (scabbing is normal and part of healing process.

Your Electrologist will give you specific instructions on after care in order to heal quickly.

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 Holistic Glow Electrology 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 therefor not predetermined by the Holistic Glow Electrology.*

Yes

I understand and comply with Holistic Glow Electrology's 24 hour cancellation policy, that if I am LATE or a NO CALL NO SHOW I will be charged the entirety of my appointment and will pre pay for the next appointment.*

Yes

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

Yes

I (your name) your name* understand I will have before and after photos taken for the technitician at Electrolysis Center files

I consent to give permission to use these photos for advertising and marketing. Photos to be used will be strictly of areas being treated. (Not to include identifying facial/ body features)

YesNo

I (your name) your name, Grant permission to Holistic Glow Electrology and its agents and employees the irrevocable and unrestricted rights to reproduce the photographs and/ or video images taken of me, during my treatment, for the purpose of: publication, promotion, illustration, advertising, or trade, in a legal manner. I hereby release Holistic Glow Electrology and its legal representatives for all claims and liability relating to said images or video. Furthermore, I grant permission to use my statements that were given during the capture/ recording moments, without my name, for the purpose of advertising publicly without restriction. I waive my right to any compensation.

I acknowledge that I am:

Over the age of 18The Legal Guardian of the following

If Legal Guardian or client (s) Please list name(s) your name . blank

Any Additional remarks for the Electrologist:

Signature*