Kravets Electrolysis

Today's Date*

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Date
Client's Name*

First NameLast Name
Date of Birth*

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Date
Gender*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

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Postal / Zip Code
How did you hear about Kravets Electrolysis?*
ChinBrowsSideburnsBeard CleanupLegsStomachBreastsBackFeetLipNeckCheeksArmsUnderfarmsChestShouldersHands
What area is priority to treat at this time?*
ShavingTweezingWaxing/sugaringLaserThreadingDepialatories (Nair)Bleaching CreamTrimmingOther
How long and how often have you used these methods?
GalvanicThermolysis/FlashBlendNoneUnkown
Describe any reactions your skin has had to previous hair removal methods
AcneBlackheadsCarcinomaCold SoresDermatitisThyroid DisorderEczemaHemophiliaEpilepsyHerpesMolesHyperpigmentationVitiligoSkin TumorsWhiteheadsCanker SoresFever BlistersPsoriasisDiabetesPCOSCongenital Adrenal HyperplasiaFolliculitisHepatitis (A, B, C)Keloid ScarsWartsHypopigmentationFacial ScarsNoneOther
PecemakerCochlear ImplantsMetal Implants/pinsDental ImplantsIUDNoneOther
YesNo
Hormone ImbalanceIrregular PeriodsMenopause (current)Post menopauseHysterectomyNone
Seabreeze Anteseptic70% alcoholAloe Vera GelNitrile glovesNone of the above
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*
Parent/guardian signature (if client is under 18 years old)
Relationship to client (if client is under 18)
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