New Client Heath History Form-Hair Removal

New Client Health History Form-Hair Removal
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
Age*
Birthdate*

MonthDayYear
Gender*

MaleFemale
How did you hear about us?*
If referred by a friend leave their name here:
What is your occupation?*
HAIR REMOVAL
Areas of concern: (Areas you would like to treat)*
Treatment area hair color:*
Hair type/thickness:*
Hair density:*
Hair Growth speed:
Approximate Age this hair growth started:
Family members with hair growth :

MotherSister(s)Grandma
Previous temporary treatment methods used in the area: (select all that apply)

PluckingShavingTrimmingWaxingSugaringCreamsThreadingBleachingSanding
Previous electrolysis?

YesNo
Which body area was treated?
Establishment
Previous Laser?

YesNo
Which body area was treated?
Establishment
When exposed to the sun... Are you the person who?*

Always burn / Never tanAlways burn, then tanSometimes burn / Mostly tanAlways tan / Never burn
Have you used a tanning bed in the last two weeks?*

YesNo
Have you used chemical sun tanning lotion in the last two weeks?*

YesNo
Are you planning a vacation in the sun in the next two weeks?*

YesNo
- The procedure may result in the following adverse experiences or risks:
  ⦁ DISCOMFORT/PAIN – Some discomfort and/or pain may be experienced during treatment.
  ⦁ REDNESS/SWELLING – Redness (erythema) or swelling (edema) of the treated area is common and may occur.
  BRUSING - There may be bruising in the treatment area.
  ⦁ HYPOPIGMENTATION / HYPERPIGMENTATION – During the healing process, there is a slight possibility that the treated area may become either lighter (hypopigmentation) or darker (hyperpigmentation) in color compared to the surrounding skin. This is usually temporary, but, on a rare occasion, it may be permanent.
  ⦁ WOUNDS – Treatment can result in burning, blistering, or bleeding of the treated area(s), but is unlikely.
  ⦁ SUN EXPOSURE / TANNING BEDS / ARTIFICIAL TANNING - May increase risk of side effects and adverse events.
  ⦁ INFECTION – Infection is a possibility whenever the skin surface is disrupted, although proper wound care should prevent this. If signs of infection develop, such as pain, heat, or surrounding redness, please call our office.
  ⦁ SCARRING – Scarring is a rare occurrence, but it is a possibility if the skin surface is disrupted. To minimize the chances of scarring, it is IMPORTANT that you follow all post-treatment instructions provided by your healthcare staff.
  ⦁ EYE EXPOSURE – Protective eyewear (shields) will be provided to you during the treatment. Failure to wear eye shields during the entire treatment may cause severe and permanent eye damage.
⦁ If any of these occur, please call our office.
Female History
Number of children
Number of miscarriages
Pregnant

YesNo
Infertility

YesNo
Regular menstrual Cycle

YesNo
Perimenoposal

YesNo
Post Menopause

YesNo
Hysterectomy

Uterus onlyUterus / ovaries
Allergies*

Topical productsCain FamilyAloeLavenderChamomileMetalsNoneOther
Medical Conditions:*

Diabetes / Healing issuesHSV1 Cold soresHVS2 WartsBlood diseases (Hep A, B, C, HIV)STDPolycystic ovarian system (PCOS)Bleeding disorderBruising or Scar easilyDizziness/FaintingCardiovascularPacemakerThyroid ConditionDepressionAnxietyEating DisordersDiarrheaNoneOther
Metal in body*

YesNo
Location of metal in body
Medications:*

Birth controlHormonesSteroidsAntidepressantsAntianxietyAnti-SeizureBlood thinnersBlood pressureThyroidAntibioticsRetin-AAccutaneHerbs (St John’s wart)BotoxFillersNoneOther
Skin observations:*

ScarringPittingKeloidsAcnePustulesComedones (black heads)EczemaRashDermatitisMolesHypopigmentationHyperpigmentationTelangiectasiasGrowthsRosaceaSkin cancerPsoriasisNoneKeratosisOther
Ethnic Background*

CaucasianHispanicAsianAfrican AmericanMediterraneanMiddle easternIndianOther
Mark in agreement to the following terms and conditions.*

I certify and attest all of the information I have provided to Hairfree Solutions is true to the best of my knowledge.I understand hair removal clinical results may vary with individual factors including: skin types, hair colors, hair types, patient compliance with pre/post treatment instructions, my pain tolerance, heredity, hormones, medical conditions and medications.I understand a series of treatments will be necessary to achieve permanency and the success of treatment is dependent on my individual commitment to the treatment schedule.I confirm I am not pregnant and I have not used Accutane within the last 6 months, I do not have a pacemaker or internal defibrillator. I have disclosed all of my medical history and medication use to Hairfree Solutions and will inform the company of any future health or medication changes.Prior to my treatment I will shower to ensure my body, hair, and face are free of dirt, sweat, lotions and makeup. I will freshen my breath.Due to the nature of treatments and insurance liabilities children are not permitted in the building.I will honor Hairfree Solutions cancellation policy and agree to pay 50% of all scheduled appointments if a 24 hour notice is not given. In the event of a no call-no show I will be charged 100% of all scheduled services. I am aware of Hairfree Solutions fee structure. I understand packages are non refundable.I consent to photographs and authorize their use for the purposes of medical audit, education, and promotion.I have received and read the pre/post treatment instructions and fully understand the content.I have been fully informed of the nature and purpose of these procedures, expected outcomes, possible complications, and I understand no guarantee can be given as to the final results obtained. I am fully aware of the conditions of these cosmetic procedures and my decision to proceed is based solely off my expressed desire to do so. I give consent to treatment to Hairfree Solutions LLCConsultations are free, however, there will be a $50 last-minute no-show cancellation charge.
Date*

MonthDayYear
Date
Signature*

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New Client Health History Form-Hair Removal

HAIR REMOVAL

Female History