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This is an Electrolysis Health History Form that must be filled out before your first electroylisis visit with The Primping Place. 

Acknowledgement Of Information (please initial each paragraph)

I understand health history information is important to the 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.

I understand that a series of treatments is necessary to achieve permanent hair removal based on my previous temporary methods of hair removal, the science of electrology, and my individual physiological factors.

I have been advised of the post-treatment healing process; the possible risks related to treatment, I agree to follow all aftercare instructions and to notify the Electrologist of any concerns or difficulty in healing.

Cancellation Policy:
Please give us a 4 hour notice or you will be charged a $25 no-show fee.

December 13, 2018

 

 

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Second Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Third Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fourth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Fifth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Sixth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Seventh Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Eighth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Ninth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Tenth Patient's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Patient's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Information:

Date of Birth *

Instructions for calling:

Referred by:
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
Select Areas To Be Treated: *
Front Hairline
Cheeks/Sidburns
Ears
Chest/Breasts
Underarms
Upper/Inner Thighs
Brows
Chin/Under Chin
Nape of Neck
Shoulders/Upper Arms
Hands/Fingers
Lower Legs
Upper/Lower Lip
Throat/Jawline
Back
Forearms
Upper/Lower Abdomen
Feet/Toes
Other
Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. SELECT ALL THAT APPLY
Fertility Problems
Weight gain/loss
Acne
Hormone/Endocrine disorder
Family History of Similar Hair Growth
Hysterectomy of Menopause
Scalp Hair Loss
Irregular Menses
Eating Disorder

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What age did hair growth begin?

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Regular menstrual cycle every _____ days.

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. Other hormone problems or explanation of above:

Hormone-Related Questions: For Females ONLY if you selected Chest/Breasts, Chin/Under Chin, Upper/lower lip, and/or Upper/Lower Abdomen. What do you believe caused your hair growth?
Previous Methods of Hair Removal. Check all that apply. *
Shaving
Cutting/Clipping
Depilatories
Electrolysis
Waxing/Sugaring/Threading
Family history of similar hair growth
Tweezer/Patch/swab
Tweezing
Hysterectomy or Menopause
Bleaching
Laser
Light-Based
Other methods
No methods used

Other hair removal methods used?

Name of previous electrologist?
How long did you use these methods of hair removal? *
Weeks
Months
Years
Not applicable
How often do you remove hair? *
Daily
Weekly
Monthly
Infrequently
Skin reactions to previous hair removal methods: Click all that apply *
Redness
Pimples
Infection
Pigmentations
Ingrown Hair
Swelling
No skin reactions
Other
Permission to photograph area to be treated?*
No
Yes

Current medications:

Reason for medications:

Past medications:

Reason for past medications:
Select all conditions,past and present that apply:
Acne
Allergy to Aspirin
Allergy to Latex
Cardiovascular disease
Breathing Problems
Cancer
Allergy to Metal
Cold Sores
Diabetes
High Blood Pressure
Pigment Problems
Skin Tags
Hepatitis
Herpes
HIV
TB
Keloids
Healing Problems
Metal Implants
Body Piercings
Pacemaker
Warts
Current Pregnancy

Other conditions or allergies:

Date of last complete physical:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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