Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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
City
State / Province
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:
*
Acne
Blackheads
Carcinoma
Cold Sores
Dermatitis
Thyroid Disorder
Eczema
Hemophilia
Epilepsy
Herpes
Moles
Hyperpigmentation
Vitiligo
Skin Tumors
Whiteheads
Canker Sores
Fever Blisters
Psoriasis
Diabetes
PCOS
Congenital Adrenal Hyperplasia
Folliculitis
Hepatitis (A, B, C)
Keloid Scars
Warts
Hypopigmentation
Facial Scars
None
Other
Allergy Sensitivy
Seabreeze Anteseptic
70% alcohol
Aloe Vera Gel
Nitrile gloves
None of the above
Current Medications
*
Oral Contaceptives
Cortisone
Hormones
High-blood pressure
Anti-coagulants
Dilantin (seizure drug)
Anti Inflamitories
None 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 agree
No, I do not agree
Client Signature
*
Parent/guardian signature (if client is under 18 years old)
Relationship to client (if client is under 18)
Continue
Continue
Should be Empty: