New Client Heath History Form-Hair Removal

  • New Client Health History Form-Hair Removal

  • Format: (000) 000-0000.
  • Gender*

  • HAIR REMOVAL

  • Family members with hair growth :
  • Previous temporary treatment methods used in the area: (select all that apply)
  • Previous electrolysis?
  • Previous Laser?
  • When exposed to the sun... Are you the person who?*
  • Have you used a tanning bed in the last two weeks?*
  • Have you used chemical sun tanning lotion in the last two weeks?*
  • Are you planning a vacation in the sun in the next two weeks?*

  • 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.
    • BRUISING - 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

  • Pregnant
  • Infertility
  • Regular menstrual Cycle
  • Perimenoposal
  • Post Menopause
  • Hysterectomy

  • Medical Questions

  • Allergies*
  • Medical Conditions:*
  • Metal in body*
  • Medications:*
  • Skin observations:*
  • Ethnic Background*
  • Mark in agreement to the following terms and conditions.*
  • Date*
     - -
  • Should be Empty: