Electrolysis Treatment Form

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Todays Date* This field is required.

Date

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Name* This field is required.

Preferred First Name

Last Name

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Pronounsshe/her/he/him/they

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Phone* This field is required.

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May RoseTreatment Room text you at this number* This field is required.We do not use text for marketing unless you have opted in. All appointment confirmations will come via text.

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Email* This field is required.

example@example.com

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Mailing Address* This field is required.

1234 Street, City, State, Zip

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Age* This field is required.

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Birth Date* This field is required.

Date

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How did you hear about RoseTreatment Room* This field is required.

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If you checked any of the above please explain

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List any medications you are currently taking

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Have you ever had Electrolysis Treatments* This field is required.Select if you've had past treatments

YESNO

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Past Electrolysis TreatmentsIf you answered yes to the previous question, please complete this section.

Area or part of body that was treated

Approximate date of last treatment

How long were you treated for

Electrologist name

Electrologist location

Reason for leaving

Did you see results/reduction from this treatment?

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Request for Electrolysis Treatment

Have you noticed a sudden change in hair growth?

If YES, please explain

Have you experienced unpleasant or unusual reactions to and form of hair removal?

If YES, please explain

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I understand that health history is important to the electrologist in order to provide safe and effective treatments.I acknowledge that all the information given is accurate to the best of my knowledge and I agree to update my health history assessment whenever there are changes.Please sign below

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Electrolysis is the only FDA-approved method for permanent hair removal. It’s most effective on hairs in the active growth stage, but not all hairs are in this phase at the same time. That’s why several sessions are needed to target each follicle as it becomes active. Factors like hair cycles, hormones, and medications can affect how long treatment takes. Side effects are usually mild, but some risks may occur:* This field is required.Checkmark each item to acknowledge

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Meticulous before- and aftercare is of the utmost importance in speeding up the healing process and avoiding pustules or damage to the treated area. For best treatment results and fastest recovery, diligently follow the instructions outlined below:

Pre-Treatment

Stay well hydrated in the week leading up to your appointment. Electrolysis works by using the moisture in your skin; hydration will make for less painful sessions as well as keeping away hyperpigmentation in most cases.
Don’t drink alcohol 2 days before your appointment; it will dehydrate you.
Avoid UV exposure leading up to your appointment (sun or tanning bed). If you develop a sunburn in the area to be treated, call to reschedule your appointment. We cannot work on sunburned skin.
Do not receive laser hair removal or skin treatments within 3 weeks before or after your appointment.
Do not wax/tweeze. Allow shaved or trimmed hairs to grow from skin in the at least 3 days before treatment.
Skin should be clean at time of appointment.
Exfoliate and moisturize the area to be treated in the week leading up to the appointment. (About 2 days prior)
Avoid caffeine before your appointment if possible; it is a stimulant and may make you more sensitive.
Do not wear perfume/scents; these trigger migraines and allergies for me and will end your appointment prematurely.

Aftercare (at least first 48 hours or until skin looks back to normal)

Clean the area with skincare products recommended by RoseTreatment Room. Antiseptics/astringents such as Sea Breeze, or witch hazel may also be used. Keep the area CLEAN.
Apply cold compress or ice to the treated area following treatment if desired.
Apply aloe or Benadryl gel for a cooling/soothing affect if desired.
Apply medicated antibiotic creams if skin is irritated or scabs are present; allow area to heal naturally. (Neosporin preferred)
If treatment is done on the face, change pillow case.
If red/dark spots or pimple-like bumps form, continue to apply antiseptic and antibiotic ointment 3 times a day; allow area to heal naturally

Refrain from these actions until skin looks back to normal after treatment

🚫 Saturating area with water, which may introduce surrounding microorganisms.

🚫 Cosmetic masks and rich creams, including bleaching creams.

🚫 Bar soaps on or around the area (at least first 24 hours. Use cleansers for sensitive skin.)

🚫 Wearing make-up (at least for the first 24 hours). If necessary, use light mineral make-up, with a single-use applicator.

🚫 Tanning or natural sunlight for at least 48 hours (use sunscreen of SPF 30 or higher and reapply every 2-3 hours).

🚫 Laser treatments within 3 weeks before or after an electrolysis treatment.

🚫 Aggressive skin treatments (chemical peels, microdermabrasion, micro-needling, etc.) within 2-4 weeks before or after an electrolysis treatment.

🚫 Touching the treated area; this may introduce bacteria (if you must touch your face, wash your hands thoroughly first).

🚫 Excessive exercising/sweating (48 hours) (this can cause breakouts in the treatment area).

🚫 Picking, scratching, or agitating area (may result in scabbing, pitting, or long-term damage to skin).

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* This field is required.Please sign below after reviewing Before & Aftercare Instruction

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Please click all items below to acknowledge* This field is required.Checkmark each item to acknowledge

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Your signature indicates that you agree to the above office policies.* This field is required.Please sign below

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Please check all that apply for your consent to media content

I, give my electrologist the absolute right and unrestricted permission to take, use, and display photographic images of methrough any form of media (print, digital, electronic, broadcast, or otherwise) at any location for art, advertising, media release,news articles, marketing, publicity, archival, or any other lawful purpose unless otherwise stated. I waive any right to royalties or other compensation arising from or related to the use of photographic images of me. I release and agree to hold harmless RoseTreatment Room and its affiliates from any liability in connection to taking or using said images.

I, for the purpose of documentation, hereby consent to “before and after” photos to document progress, reactions, and/or research

I give consent to sign up for communication from RoseTreatment Room via email. My email should not be shared with other parties.

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INFORMED CONSENT

...is both a process and a document; neither can stand alone as informed consent. The informed consent process must include a verbal review (consultation) of the procedures, alternatives, and risks of electrolysis procedures, as well as an opportunity for the client to ask the electrologist any question about electrolysis treatments. The informed consent document must be signed by you, the client.

Please take the consultation as an opportunity to ask any questions you may have regarding the electrolysis procedure, including questions about any possible risk. An electrologist is not a physician, and cannot make medical referrals. An electrologist may obtain advice from a client's physicians regarding medical information needed to safeguard client and electrologist. Advice from the physician will be documented in the client record.