Electrolysis Client Consent form Logo

  • Electrolysis Client Consent Form

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  • Some medical conditions may be a contraindication to the following procedure, so it is important you provide the information below. It is ultimately your responsibility to ensure that you understand in full the electrolysis procedure and the expected outcomes before your treatment commences and inform therapist of any changes to below between sessions

  • Please check all of the following that pertain to you:

  • If you suffer from any of the above please ensure that you notify your therapist who can take the necessary precaution so you receive the best treatment to avoid any risks to your health.

  • In relation to Electrolysis treatments I have been advised of the following:

  • 1. Treatment is successful on most clients, but my individual results cannot be guaranteed

    2. Most clients require 6 to 12 months of treatments to achieve best results, some may require less or more. Individual results depend on many factors, therefore it is extremely difficult to advisean exact number of treatments.

    3. Darker skin type clients will require additional treatments due to low intensity application.

    4. Exposure to uv rays will compromise my treatment, therefore I will use spf30+

    5. Not following strict aftercare advice will reduce the efficacy of my treatment.

  • Risks associated with Electrolysis Treatment

  • Even though the risk of complication is extremely low, the following can occur:

    - Scabbing may occur after the treatment as part of the healing process - scabs should not bepicked off by the client

    - Blanching or burning - this will happen immediately with the appearance of a white ring on theskin's surface.

    - Other potential risks include crusting, itching, pain, bleeding, bruising, pimple like bumps, dry skin, hypopigmentation (lightening of skin), hyperpigmentation (darkening of the skin), blistering, burns, infections, scabbing, swelling, a very small risk of scarring and a failure to achieve the desired result.

    - Allergic or delayed inflammatory reactions can develop. A test patch is performed to ascertain the reaction of the skin prior to initiation of treatment.

    - I consent to photographs taken to evaluate effectiveness. Photographs revealing my identity will not be used without consent.

  • - I understand the sensation of Electrolysis is sometimes uncomfortable and feels like a mildzapping, heat, prickling sensation.

    - I am aged 18 years or over

    - I will advise (salon/my therapist) of any changes that occur betwwen treatments for the duration of my treatments that can increase potential risks or reduce efficacy eg new medications, sun baking etc.

    - I also understand that there will be no refund for any performed services.

  • In relation to my initial and all subsequent treatments I advise that:

  • - I have not used mechanical epilation, waxed or tweezed in the treatment area in the last 72 hours
    - I have no history of seizures and I have disclosed all known allergies
    - I have not had unprotected sun exposure including tanning beds and fake tan creams in the past 4 weeks
    - I am not taking medications causing photosensitivity eg. antidepressants, accutane
    - I do not have a history of keloid scarring
    - I do not have active infections
    - I do not have open lesions in the areas which are being treated
    - I do not have herpes
    - I have not used retin A in the past 2 weeks
    - I have not had laser resurfacing within the last 6 months
    - I have not had a chemical peel within the last 4 weeks
    - I do not have diabetes
    - I am not pregnant or breastfeeding
     

  • Aftercare

  • The area should be kept clean, use clean sheets and pillow cases. Applying colloidal silver and aloe vera gel can help reduce risk of infection post tx. Once at morning and at night the client should apply the aftercare ointment of aloe and colloidal silver if concerned. Hyaluronic Acid may also be applied for moisture and to increase client healing. This should be repeated a minimum of 2x per day. If the client wishes to wear foundation / makeup it should be recommended for use the next day, Mineral powder foundation is recommended until fully healed, avoid talc and alwasy use clean makeup brushed and no actives. The use of SPF is advised to be a zinc based sunscreen.

  • Be aware of down time

  • Clients often find application of ice packs or Cooling Aloe Gel can soothe and help reduce swelling. Further information on all products recommended is available on request. Anti-inflammatorymedication and/or antihistamine medication may help initially after treatment and for a day or so afterwards.

  • After Electrolysis treatment, it is important to closely observe the following aftercare advice:

  • - Burning sensation will soon reduce and anti-inflammatory / anti histamine medication can help especially if you get itchy.
    - Following your treatment do not touch or scratch the area treated this can cause infection in the treatment area.
    - Ice packs, cryo balls and Cooling Aloe Gel can soothe the treatment area.
    - Avoid perfume or alcohol based products.
    - Use sun protection if out and about
    - Do not swim in chlorinated pool water 48 hours post treatment.
    - Contact for advice if the area becomes hot, red or continues irritation.
    - Remember some regrowth is to be expected, continue with ongoing treatments when necessary to gain best results possible.

  • By signing below, I agree to the following:
    I have completed this form to the best of my ability and knowledge. I understand the importance of my accurate and complete medical history. I understand that withholding any of my medical information may be detrimental to my health and safety during and after the procedure. I understand that if there is any change in my medical history it is my responsibility to inform my therapist. I agree to inform my therapist of any changes in the above information. I agree that I do not have any conditions that would make the requested treatment unsuitable. I will inform the therapist of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward
    my therapist and the salon for any injury or damages incurred due to any misrepresentation of my health.

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