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?*
What area is priority to treat at this time?*
Do you have any of the following conditions? If yes, please select them:*

AcneBlackheadsCarcinomaCold SoresDermatitisThyroid DisorderEczemaHemophiliaEpilepsyHerpesMolesHyperpigmentationVitiligoSkin TumorsWhiteheadsCanker SoresFever BlistersPsoriasisDiabetesPCOSCongenital Adrenal HyperplasiaFolliculitisHepatitis (A, B, C)Keloid ScarsWartsHypopigmentationFacial ScarsNoneOther
Allergy Sensitivy

Seabreeze Anteseptic70% 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
Please briefly describe how you have previously removed hair in this area, including: – methods used (e.g., shaving, waxing, laser, tweezing, etc.) – how often you used them – for how long – and when was the last time you used each method (especially tweezing, waxing, or laser) Example: shaving 2–3 times per week for 2 years; tweezing occasionally; laser — 6 sessions; last tweezing 1 week ago, last shave 3 days ago.
Photography & Treatment Documentation Consent. I understand and agree that photos of the treatment area may be taken before and/or after the procedure for documentation and treatment purposes. These images are used to track progress and ensure the quality of treatment, and will remain confidential.*

I agree
I give permission for anonymized photos of my treatment area to be used for educational or promotional purposes (e.g., before/after results). No identifying features will be shown.*

Yes, I agreeNo, I do not agree
Client Signature*
Parent/guardian signature (if client is under 18 years old)
Relationship to client (if client is under 18)
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