Electrolysis Intake Form Logo
  • Electrolysis Intake Form

    This form must be completed before consultation and first session with Zap Master Electrology
  • Zap Master Electrology is dedicated to providing permanent hair removal services through training, & clinic insurance consulting under the expert care of Stephanie Shields, CPE CLS, our certified electrology instructor. If you are referred to us by your electrologist for a medical electrolysis assessment, once your treatment is approved by your insurance company, Stephanie will ensure that your ongoing treatments are redirected to your home clinic contracted with Zap Master consultation services. please provide your clinic name below if you were referred from elsewhere. 

  •  - -
  • Powered by Jotform SignClear
  • Medical Skin & Hair History

    ALL ZME patients please fill out the following information. These questions are industry standard. Failure to complete this section will result in a lack of understanding the "why" to your growth.
  • Contraindications & Medical Hair History

    This area asks questions pertaining to known contraindications to electrology, as well as known factors that influence hair growth.
  • Potential Allergy For Products Used During Services

    We are a non latex facility
  • Service products commonly used at Zap Master.

    At Zap Master Electrology, every product we use is carefully chosen with a purpose: to support your skin's health and enhance your treatment experience. All our products are non-comedogenic, meaning they won’t clog pores, and they are specifically formulated to soothe, protect, and promote healing without compromising skin integrity.It’s important to note that product selection matters. Using the right post-treatment care is essential for optimal healing and achieving the best results. If you have any allergies, please inform us beforehand, as choosing products that are unsuitable for your skin can potentially compromise your healing process. Our goal is to ensure your comfort, safety, and satisfaction throughout every step of your journey with us.
  • Pre-service products:

  •  LimpiDerm Deep-Cleansing Gel


    Use: A deep-cleansing gel for lipidic and acne-prone skin types, formulated to eliminate excess sebum and purify the skin

    Home use:Prepares skin for comedone extraction.
    Supports daily cleansing for acne-prone and seborrheic skin.

    Key Ingredients:

    • Lemon and Geranium: Astringent and regenerating.
    • Retinyl Palmitate (Vitamin A): Antioxidant and moisturizing.
    • Burdock Root and Calendula: Anti-inflammatory and calming.
    • Cucumber: Refreshes and soothes.

  • Sensibilis Pre-Epilation Lotion

    Use: this lotion prepares cleanses and soothes the area.
    Offers a calming and invigorating effect.
    Creates a clean environment for safe and effective hair removal.

    Key Ingrediants: 

    With essential oils of lavender, rosemary, lemon, and camphor,  

  • Post service products:

  • Sensibilis Post-Epilatory Gel

    Use: A soothing gel designed to nourish and hydrate the skin after treatments

    Active Ingrediants:

    Aloe Vera: Provides deep nourishment and anti-inflammatory benefits.

    Witch Hazel: Tightens tissues and promotes healing.

    Arnica: Reduces redness and soothes irritation.Licorice Root: Offers anti-inflammatory and calming properties.

  • Yi-zhi Regenerating Crème-Balm

    Use:
    Uses:Soothes post-treatment inflammation.
    Provides relief for irritated or acne-prone areas.
    Promotes skin repair and revitalization.
    Note: Not recommended for use by pregnant or nursing individuals.

    An ultra-refreshing and antiseptic balm perfect for calming the skin after electrolysis or other treatments:

    Key Ingredients:

    Shea Butter: Nourishes and revitalizes.

    Camphor and Menthol: Provide antiseptic, decongestive, and calming effects.
    Tea Tree, Lavender, and Rosemary Oils: Regenerate, soothe, and protect the skin.

    Aloe Vera: Softens and hydrates the skin.

  • Calmoseptine:
    A time-tested product for areas of high friction or heavier clearance areas

    Use:Provides protection. 

    Forms a protective barrier to shield sensitive skin.

    • Relief: Soothes irritation caused by friction or extended treatment sessions.
    • Healing Support: Reduces redness and promotes recovery.
      This versatile ointment is ideal for post-treatment care, particularly in areas prone to irritation or discomfort due to friction or dense hair clearance.

    Key Ingrediants:

    • ZINC OXIDE
    • MENTHOL
  • Hair History

    ALL patients please fill out the following information
  • Hair Density Self Assessment

    The modified Ferriman-Gallwey (mFG) scoring system is used to diagnose hirsutism and determine the level of severity: The mFG score is based on a visual assessment of nine body areas that are sensitive to androgens. Each area is scored from 0 to 4, with 0 indicating no hair and 4 indicating full male pattern hair growth. The total score is used to determine hirsutism and severity: Hirsutism: A score of 8 or greater is considered hirsutism in British and U.S. Black and White women, 9 or greater in Mediterranean, Hispanic, and Middle Eastern women, 6 or greater in South American women, and 2 or greater in Asian women. Severity: A score of up to 15 indicates mild hirsutism, while a score greater than 25 indicates severe hirsutism. 
  • Assessing Hair Density, Hirsutism & Hypertrichosis

    This section is for the CIS gender & Transgender patients experiencing excess "male patterned" hair growth needing electrolysis.
  • *To proceed with your insurance coverage for hair removal, you'll need a Letter of Medical Necessity from the provider who will perform the procedure. This letter should detail the size and location of the treatment area, along with the expected number of units needed per body region for a comprehensive treatment plan.

    Terminal Hair Growth Description:

    Terminal hair refers to the mature, fully developed hair that is coarser, thicker, and darker compared to vellus hair, which is the fine, light-colored hair commonly found on various parts of the body. Terminal hair is typically found in areas influenced by hormones, such as the scalp, armpits, and pubic region. During puberty, hormonal changes trigger the transformation of vellus hair into terminal hair in certain areas, contributing to the development of secondary sexual characteristics.

    Pictured below is an example of terminal growth 

  • Image-18
  •  
  • Photo Documentation of Initial Growth - NO GENITAL PHOTOS

  • PHOTO REQUIREMENTS (virtual consults and insurance requirements)

    Photos of the requested area to be treated from approximately two feet (include a method of hair removal used in the following photo series for documentation): 

    Before Hair Removal

    • Face and neck: Recommend 8-12 hours of hair growth; include the length of time from last hair removal) 

    • Body: Recommend 1-2 weeks of hair growth to visualize hair distribution, thickness, etc. Genital body region photos are not needed. 

    Immediately after hair removal:

    The client may remove the hair before bed for the “immediately after hair removal pictures.” Then in the morning, take pictures again to demonstrate the "before" hair growth. 

    Phone Camera: Use to the camera on the backside of your phone. NO soft focus filters or "beauty" filters when takeing the pictures. The picture below is an example of the face pictures.  

  • Image-57
  • YOUR PHOTO SUBMISSIONS MUST BE EMAILED TO: INFO@THEZAPMASTER.COM AT LEAST 48 HOURS BEFORE YOUR CONSULTATION

    If you are seeking body electrolysis clearing as well DO NOT SEND GENITAL/ OR AREOLA Photos by submitting your photos before your consultation you will expedite the insurance approval process AND better inform your technician of goals.
  • Areas of Interest & Order of Importance

    Please indicate the areas of interest
  • Service Understanding

    Electrolysis & Laser Hair Removal
  • Electrolysis

    The concept of using electric current for hair removal has been available since the late 1800s and has been improving ever since.

    Electrolysis treatments are a form of electrical epilation where a single-use, disposable wire filament is inserted into the hair follicle (a natural opening in the skin) and a minimal amount of current is delivered to the root of the follicle to destroy it through a variety of modalities. All modalities will affect only the active hair follicle, making this a direct route to target unwanted hair.


    In the early stages of treatment, you will be treating more frequently to break down their strength in the early stages of their growth cycle. It is imperative that we treat hairs in the recommended treatment pattern your electrologist determines necessary for your unwanted hair needs. This frequency will change as the number of hair lessons/weakens/ or both.

    There are three types of electrolysis:


    Galvanic Electrolysis - Galvanic electrolysis is the oldest type of this hair removal. The direct current used is extremely effective but slower. It creates a chemical change in the follicle to disable the root.
    Thermolysis – Thermolysis uses shortwave radio frequency or AC current. Thermolysis causes the water molecules by your hair to rapidly vibrate, which produces heat. When enough heat is created, thermolysis damages the cells that cause hair growth.
    Blend Electrolysis – This method combines both galvanic and thermolysis into one process. The heat from thermolysis heats up the chemical created in the galvanic and speeds up the process.
    Your electrologists will select the modality that best serves the hairs requested. There may be contraindications that keep you from a modality which is why we request your health history information pertinent to our work. It is not uncommon to use all modalities when working on one client.

     

    Understanding Laser Hair Removal
    Laser hair removal is a medical procedure that uses concentrated beams of light (lasers) to target and reduce unwanted hair. The process involves directing the laser's light energy to the pigment (melanin) in the hair follicle, which absorbs the light and converts it into heat, disabling the follicle and delaying future hair growth.

    The Science Behind Laser Hair Removal
    How It Works: The laser targets the melanin in hair during its active growth phase (anagen). Multiple treatments are necessary to catch all hairs in this phase, as hair growth occurs in cycles.
    Effectiveness: Results vary based on skin tone, hair color, and hair density. Darker hair and lighter skin typically yield the best results, though advancements in technology allow for safe and effective treatments on a broader range of skin tones. 

     

    Patient Care
    Pre-Treatment Instructions:

    Avoid sun exposure and tanning for at least two weeks prior to treatment.
    Refrain from waxing, plucking, or using depilatory creams for 4-6 weeks before treatment. Shaving is acceptable and recommended 24-48 hours before your session.
    Avoid skin irritants like retinoids or exfoliants in the treatment area 2-3 days before treatment.


    Post-Treatment Care:

    Redness and swelling around the treated follicles are common and temporary. Apply a soothing lotion or aloe vera gel as needed.
    Avoid direct sun exposure and use sunscreen with SPF 30 or higher on treated areas.
    Avoid hot showers, saunas, and exercise that causes sweating for 24-48 hours.
    Refrain from waxing, plucking, or exfoliating the treated area between sessions.
    Treatment Expectations

    • Number of Sessions: A series of 6-8 treatments spaced 4-6 weeks apart is typically required for optimal results, depending on the treatment area and individual hair characteristics. Maintenance sessions may be needed annually.
    • Side Effects: Temporary discomfort, redness, and swelling are the most common side effects. Rarely, hyperpigmentation or hypopigmentation may occur. Inform your provider if you experience any unexpected reactions.
    • Limitations: Laser hair removal reduces hair growth but may not result in complete removal. Fine, light-colored, or gray hair will not respond well to treatment.
       
  • Electrolysis Consent

    Please sign and acknowledge that you have read and approve Zap Master Electrology to perform electrolysis permanent hair removal
    1. I understand health history information is important in order to provide me with safe and effective treatments.               
    2. I acknowledge all information given by me is accurate to the best of my knowledge.  
    3. I agree to update my client profile whenever there are changes.
    4. I know that hair removal will take a series of treatments to achieve satisfactory results.
    5. I have been told that the success of my treatments will depend on my cooperation with my treatment schedule, my pain tolerance, inherited hair growth patterns, and any other instructions explained to me or recommended by the technician.
    6. I have been advised of the post-treatment healing process, the possible risks related to treatment, and I agree to follow all after-care instructions given to me by the technician.  I will notify the provider of the treatment of any difficulties in healing.
    7. I understand and acknowledge that all deposits and payments for the above procedure are non-refundable unless I cancel my appointment at least two days prior to the procedure.
    8. I acknowledge that all the information provided is to the best of my knowledge, and that it is important to keep this information up to date, especially medications, medical conditions and pregnancies, at each appointment.  
    9. I also acknowledge that I accept full responsibility for my care.
  • Powered by Jotform SignClear
  • Appointments Cancellation Policy

  • Please notify within the time frames listed below when canceling or changing an appointment:

    • 24 hours notice for appointments one hour or less.
    • 48 hours notice for appointments more than one to less than three hour(s).
    • 5 days for any treatment 3+ hours

    This allows for adequate notification will allow for any openings to be filled.


    A $35.00 charge will be incurred for any violations of our cancellation policy for appointments with the electrologists, nurses or aestheticians for appointments of two hours or less.

    Being late for an appointment is included in the treatment time.


    Reminders that are sent out days prior to your appointment.However we do expect you aswell to note your appointment date and time. You are equally still responsible for your appointment whether or not you receive your reminder.


    Invoices are sent to violations of the above polices and must be PAID IN FULL. Repeated offences (3 or more) will result in the cancellation of future appointments until you are able to resume a commitment to your electrolysis scheduled goals. 

    Self pay customers: Three violations of our cancellation policy or “no shows” will require prepayment of the treatment.

     

  • Powered by Jotform SignClear
  • Should be Empty: