Electrolysis & Advanced Electrolysis Intake Form

Electrolysis & Advanced Electrolysis Intake Form
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Other
Date

MonthDayYear
Date
Date of Birth

MonthDayYear
Date
Name

First NameLast Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
If referred, by who?
Emergency Contact

First NameLast Name
Relationship to Emergency Contact
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your Medical History
Are you currently under the care of a physician?
If Yes, who?
Have you experiences any of these health conditions in the past or present?

Other
Any known allergies?

Other
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.
Your Skin
Briefly tell me what brings you into ElimiLuxe Electrolysis?
What would you say your skin type is?
Do you currently use:
Have you experienced any of the following:
Have you received any of these hair removal services?
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
Should be Empty:

Electrolysis & Advanced Electrolysis Intake Form

Your Medical History

Your Skin