Client Health History Form

Rubiology
237 W. 4th St.
Claremont, CA 91711
phone or text: 909.624.8617
https://www.therubiology.com/
rubiologyelectrology@gmail.com
IG rubiology__
Client Health History Assessment

Collecting medical and personal information is crucial for providing safe and effective electrolysis treatments at Rubiology
Client Information

Here at Rubiology, we have all our employees sign a Non-Disclosure Agreement (NDA) and a Rubiology Confidentiality Agreement. All personal information, documents and personal files you provide are kept confidential & securely in your guest profile and will be used solely for the purpose of ensuring your safety and the effectiveness of your treatments.
Guest Name*

Legal First NameLegal Last Name
Preferred Name:
Gender Identified as:
Date of Birth:*

MonthDayYear
Client Date of Birth
Today's Date:*

MonthDayYear
Date
Company Email
example@example.com
Guest Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guest Phone Number*
Please enter a valid phone number.
Guest Email*
example@example.com
Emergency Contact Information

In the unlikely event of an emergency, having your emergency contact information allows us to quickly reach out to someone who can assist.
Emergency Contact Name:*
Name of person to contact incase of emergency
Emergency Contact Phone Number*
Please enter a valid phone number.
Contact Preferences
NEW CLIENT VIRTUAL CONSULTATION - How would you prefer to chat?*

FaceTimeGoogle DuoAudio phone callOther
How can we contact you for appointment changes & reminders? Check all that apply:*

CallTextEmail
Hair Removal Information

Different skin types and sensitivities respond differently to electrolysis. By understanding your skin type and previous reactions from past treatments, we can adjust the equipment settings and techniques to minimize discomfort and maximize effectiveness.
Please Check all areas you wish to be treated
Head:*

Upper Lip/MustacheChinBeardEyebrowsUnibrowEarsSideburnsHairlineNeckNoneOther
Body:*

ArmpitsBreast/ChestNavel/Happy TrailBikini/GroinAnusPenis ShaftUpper BackLower BackNoneOther
Limbs:*

ShouldersUpper ArmsLower ArmsHandsFingersOuter ThighsInner ThighsLower LegsAnklesFeetToesNoneOther
Previous Hair Removal Methods

Hair Removal Methods - What hair removal methods do you most frequently use? {select all that apply}*

	Times Per Day	Times Per Week	Times Per Month	Other
Waxing
Sugaring
Tweezing
Creams
Laser
Threading
Shaving/Trimming
Other

Dermabrasion:*
Please select yes or no
Last Dermabrasion Treatment:

MonthDayYear
Date
Skin History
Skin Health

Please be as detailed as possible.
Have you ever had acne?*

Yes, I have acne currentlyYes, but not currentlyNo, I have never had acne
If you selected YES, how would you describe your acne?
Are you currently on any form of Acne or other Skin Health related Treatment? Please write the products and how you use them below. *
Skin Reactions
Skin reactions/irritation to any previous hair removal methods? {select all that apply}*

NoneRednessSwellingIngrown HairInfectionBumps/PimplesOther
Previous Electrolysis Treatments
Have you ever had Electrolysis before?*
Please select yes or no
If yes, pleases provide your Electrologist's Name and/or Location:
Date of last treatment:

MonthDayYear
Date
Treatment areas:
Please list areas worked on
Total # of treatments:
Modality: {select all that apply}

ThermolysisBlendGalvanicNot sure
Medical History

Understanding your medical history helps us identify any conditions that might affect your treatment, such as skin conditions, allergies, or circulatory issues. This ensures we can tailor the procedure to your specific needs and avoid any adverse reactions.
Medications

Some medications can affect skin sensitivity and healing. Knowing what medications you are taking allows us to adjust the treatment accordingly and ensure your safety.

List All Medications & Vitamins You are Currently Taking:*

	Name/Purpose
Medication or Vitamin Name
Medication or Vitamin Name
Medication or Vitamin Name
Medication or Vitamin Name
Medication or Vitamin Name
Medication or Vitamin Name

Allergies

Information about any allergies, particularly to metals or topical products, helps us avoid using any substances that could cause an allergic reaction during the treatment.

List All Allergies:*

	Comment
Allergy
Allergy
Allergy
Allergy
Allergy
Allergy

Additional Comments
Past & Present Health Conditions
Skin Conditions: {select all that apply}*

N/AAcneCold SoresDermatitisHealing IssuesKeloidsPsoriasisRosaceaSkin TagsWartsOther
Health Conditions: {select all that apply}*

N/ABreathing ProblemsCancerCardiovascular DiseaseClotting IssuesCOPD (Chronic Obstructive Pulmonary Disease)DiabetesDizzinessHeart AttackHepatitisHerpesHigh Blood PressureHIVInfertilityKidney DiseasePCOS (Polycystic Ovary Syndrome)StrokeTB (Tuberculosis)Thyroid DiseaseVertigoOther
Body and Skin Modifications and/or Implants: {select all that apply}*

N/ABody PiercingsFace PiercingsMetal ImplantsPacemakerOther
Have you had any major surgeries?*
Please select yes or no
If yes to major surgeries, please specify:
Please specify surgery information
Are you pregnant or planning to become pregnant:*
Please select yes or no
Do you get your period:*
Please select yes or no
If yes, is it regular:
Please select yes or no
Are you preparing for sex reassignment surgery*
Please select yes or no
Physician’s Name:
Physician's name for planned surgery
Physician's Phone Number:
Please provide your physicians phone number
Physician’s Location:
Please provide physicians location
May we contact your physician to discuss your treatment plan:
Please select yes or no
Additional Information
How did you hear about us?*

Friend/FamilyWebsiteFacebookInstagramPinterestGoogleOther
Photo Consent for Progress Tracking & Media Release
To provide the best service and monitor your progress, we may take photos during your initial visit and throughout your treatment. These photos will be kept confidential and are solely for tracking your treatment progress. They will remain securely stored in your customer profile and will never be shared without your explicit consent. If you choose to allow us to use your photos or videos for social media or marketing purposes, you will be informed and asked to sign a separate media release form. ***Photos of private areas are never taken or used under any circumstances.****

I understand
Do we have permission to document your hair removal progress in photos and/or videos to use as promotional material for our company’s print and/or digital publications?*
If at any time this answer changes, please update Rubiology team members of your knew preference
Photographs:*
Please select yes or no
Video:*
Please select yes or no
Additional Comments & Questions:
Client Acknowledgement of Information
I understand health history information is important to my Electrologist in order to provide me with safe and effective electrology treatments. I acknowledge all information given by me is accurate to the best of my knowledge, and I agree to update my health history assessment whenever there are changes.*
Initials
I understand that electrolysis requires a series of treatments in order to achieve permanent hair removal and my progress will be impacted by my personal hair growth rate, the science of electrology, and my individual physiological factors.*
Initials
I have been advised of the pre and post-treatment care, the healing process and the possible risks related to treatment. I agree to follow all aftercare instructions and to notify my Electrologist of any concerns or difficulty in healing. *
Initials
I understand my electrologist has the right to refuse treatment if it is not beneficial to my health or skincare due to know nor unknown health conditions I may have.*
Initials
Guest Name*

First NameLast Name
Are you 18 or older:*

YesNo
Guest Signature*

Clear
Date of Guests Signature:*

MonthDayYear
Date
Parent/Guardian's Name:*
Parent’s Name
Parent/Guardian's Signature:*

Clear
Date of Parent/Guardian's Signature:

MonthDayYear
Date
THANK YOU FOR YOUR BUSINESS

Rubiology Team
Should be Empty:

Client Health History Assessment

Client Information

Emergency Contact Information

Contact Preferences

Hair Removal Information

Please Check all areas you wish to be treated

Previous Hair Removal Methods

Skin History

Skin Health

Skin Reactions

Previous Electrolysis Treatments

Medical History

Medications

Allergies

Past & Present Health Conditions

Additional Information

Photo Consent for Progress Tracking & Media Release

Client Acknowledgement of Information

THANK YOU FOR YOUR BUSINESS