Serenity Electrolysis - Client Health Questionnaire

Serenity Electrolysis - Client Health Questionnaire

Fill out this health questionnaire to help us prepare for your electrolysis treatment. Please answer all questions accurately and complete the consent and signature sections.
Client Information
Full Name

First NameMiddle NameLast Name
Gender
Preferred Pronoun
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
How did you learn about us?
Email
example@example.com
Hormone Related Questions
What age did unwanted hair growth begin?
Regular menstrual cycle?
Are you pregnant?
If yes, how far along are you?
PMOS (formerly PCOS)
Hormone/Endocrine Disorder
Scalp Hair Loss
General Health Questions
Select all conditions, past and present, that apply:

Other
Are any selected health conditions ongoing or resolved?
Are you under a doctor's care?
Recent surgery or injury
Medications and Treatments
Do you take medication?
If yes, please specify what medication you take and what it is for (type N/A if none).
Do you take supplements?
If yes, please specify what supplements you take and what they are for (type N/A if none).
Do you take/use any of the following:

Other
Cosmetic Treatments
Have you ever had:

Other
Date of last cosmetic treatment:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Hair Removal Methods
Previous hair removal methods

Other
How often do you remove the hair?
Have you ever had electrolysis treatments?
If yes, on which part of the body?
Have you ever had laser/IPL treatment?
If yes, on which part of the body?
Have you had a sudden growth of hair on areas previously treated with laser?
Skin reactions to previous hair removal methods

Other
Areas to Be Treated for Permanent Hair Removal
Select all areas to be treated

Other
Other Area to Be Treated
Acknowledgement of Information and Consent
I understand and agree that:

Cancellation, No-Show & Late Arrival Policy: Your appointment is reserved especially for you. We understand that schedule changes may sometimes be necessary and respectfully request at least 24 hours’ notice for cancellations. No-shows, late cancellations, and late arrivals are subject to a 100% charge of the scheduled treatment. If you arrive late, your appointment will end at the originally scheduled time and will not be extended.
Permission to Photograph
Legal Parent/Guardian consent
By entering your name below, you acknowledge that this serves as your signature and that the information you’ve provided is accurate. You confirm that you have read, understood, and agree to the statements and acknowledgements above. You voluntarily consent to receive electrolysis treatment from Serenity Electrolysis LLC.
Client Signature
Client Signature - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Legal Parent or Guardian Signature
Legal Parent or Guardian - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Typed Name
Should be Empty:

Serenity Electrolysis - Client Health Questionnaire

Client Information

Hormone Related Questions

General Health Questions

Medications and Treatments

Cosmetic Treatments

Previous Hair Removal Methods

Areas to Be Treated for Permanent Hair Removal

Acknowledgement of Information and Consent