MEEC Model Intake Health Questionnaire

  • Maryland Electrolysis Education Center Model Intake Health Questionnaire

    Fill the form below and we will get back soon to you for more updates and plan your appointment.

  • *Due to student graduation, we are putting all applications on a waitlist until further notice*

  • Sex Assigned at Birth*
  • Format: (000) 000-0000.
  • Preferred Contact Method*
  • How did you hear about us?*

  • Treatment and Medical History

  • Are you currently seeing a physician/therapist regularly?*
  • Are you currently seeing a dermatologist regularly?*
  • Do you have any allergies or intolerances?*
  • Describe your diet:*
  • Do you consume any of the following daily?*
  • Have you had any of the following?*
  • Type of sun exposure*
  • Do you undergo or use any of the following skin care treatments?*
  • Topical Retinoids*
  • Oral Retinoids*
  • Bleaching Agents*
  • Acids*
  • Benzoyl Peroxide*
  • Exfoliation and Resurfacing*
  • Chemical Peel*
  • Are you a smoker?*
  • Do you get cold sores/fever blisters?*
  • Are you sensitive to alcohol-based products?*
  • Are you taking any other medications/supplements/vitamins at this time? (Excluding medications that affect your hormones or endocrine system)*
  • Do you have any medical conditions or autoimmune disorders?*
  • Have you undergone/plan to undergo any medical procedures?*
  • Are you pregnant?*
  • Are you lactating?*
  • Are you in or past menopause?*
  • Are you currently taking any hormone therapy (HRT) or medications that affect your hormones or endocrine system?*
  • Please select what type of hormone therapy (HRT) or other medication that affect your hormones or edocrine system:*
  • Estrogen & Progesterone (Feminizing or Menopausal HRT)*
  • Testosterone (Masculinizing HRT)*
  • Anti-Androgens*
  • Birth Control Pills or Contraceptives*
  • Thyroid Medications*
  • Other Endrocrine-Impacting Medication*
  • Do you have any medical concerns pertaining to the following body systems?
  • Skin
  • Circulatory
  • Respiratory*
  • Uro/Digestive*
  • Musculoskeletal*
  • Neurological*
  • Degenerative*
  • Endocrine*
  • Have you had electrolysis before?*
  • Last Treatment Date*
     - -
  • What methods of hair removal have you tried?*
  • Have you had sudden outbreak of hair growth in the treated areas?*

  • Photo Release Form

  • I, [Name], hereby grant permission to Maryland Electrolysis Education Center Inc (MEEC) to take and use photographs, videos, and other digital media of me during my participation in courses, events, and activities provided by the schoo.

     

    Use of Media

    I understand that the photographs and videos may be used for educational, promotional, and marketing purposes, including, but not limited to, brochures, websites, social media, advertising, and other materials, without further compensation or approval from me.

     

    Rights Granted

    I acknowledge that I am granting the school full rights to use my likeness in promotional materials and will not hold the school, its employees, or agents liable for any claims regarding the use of these images.

     

    Duration of Release

    This release shall remain effective indefinitely, unless I provide written notice to the school to revoke this permission.

     

    No Compensation

    I understand that I will not receive financial compensation for the use of my image or likeness beyond the services provided by the school.

     

    Governing Law

    This release shall be governed by the laws of the State of Maryland

  • Availability

  • The Maryland Electrolysis Education Center is open during the following days and times:

    Thursday 11:00-6:30
    Friday 10:00-4:30
    Saturday 9:00-4:30

  • By signing, you agree to the following:

  • Should be Empty: