Electrolysis & Advanced Electrolysis Intake Form

Electrolysis & Advanced Electrolysis Intake Form
Select your pronouns*

She/HerHe/HimThey/ThemZe/HirPrefer not to sayOther
Date*

MonthDayYear
Date
Date of Birth *

MonthDayYear
Date
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?*

Walked byFacebook/InstagramOnline SearchReferral
If referred, by who?
Emergency Contact*

First NameLast Name
Relationship to Emergency Contact*
Emergency Contact Phone Number*
Please enter a valid phone number.
Your Medical History
Are you currently under the care of a physician?*

YesNo
If Yes, who?
Have you experiences any of these health conditions in the past or present?*

Hormone ImbalanceCancer/ Systemic diseaseDiabetesHigh Blood PressureDysphoriaHeart problemArthritisAuto-immune DisorderAsthmaEpliepsy/SeizuresCold soresHIV/AIDSLupusDepression/AnxietyHeadaches/ MigranesPacemaker/ICDs/VADsMetal PlatesNonePregnant/BreastfeedingOther
Any known allergies?*

LatexAsprinBotanicalsLidocaneFragrance/essential oilsSunscreenNoneOther
Please list below any specific substances you are allergic to.
List medications/supplements you are currently taking.*
Have you ever received any botox or fillers? If so, how long ago?
Please rate your pain tolerance level.*

LowMediumHigh
Your Skin
Briefly tell me what brings you into ElimiLuxe Electrolysis?*
What would you say your skin type is?*

Normal (no visible blemishes, fine pores, smooth texture)Sensitive (reactive to fragrance, often irritated)Combination (oily and dry patches, oily t-zone, hormonal breakouts)Oily (enlarged pores, excessive oil)Acne (cystic or nodules)Dry (dull, visible lines and wrinkles, feels tight)
Do you currently use:*

Prescribed topical creamExfoliant (physical or chemical)AccutaneVitamin A derivative (retinol/retonids)AHA (glycolic acid, lactic acid, etc.)Other Active ProductsBHA (salicylic acid)SPFNone
Have you experienced any of the following:*

PIH (Post Inflammatory Pigmentation)RosaceaHyperpigmentation (Overproduction of melanin)Hypopigmentation (Underproduction of Melanin)Keloid ScarringNone
Have you received any of these hair removal services?*

Waxing/sugaring/tweezingThreadingLaser/ElectrolysisNone
If Yes, what area and for how long?
I acknowledge that I must adhere to the policies. I understand that cancellations must be done with at least 48 hours notice. Failure to do so will result up to 75% of the total service cost. I understand that tardiness does not result in a pro-rated fee. If you are late, your session will still end at the scheduled time, and you will be charged the full amount for the total time originally booked.
Signature*
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Electrolysis & Advanced Electrolysis Intake Form

Your Medical History

Your Skin