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Advanced Electrolysis Intake and Consent

The following side effects are uncommon but possible with Advanced Electrolysis treatments:

  1. (most common) Pain/sensation during treatment: You will feel sensation during treatment that could be mild or painful depending on your individual tolerance level.
  2. Bleeding: Pinpoint bleeding may occur during treatment. Rarely will bleeding interfere with a treatment but depending on the blemish being treated, it may cause for a follow up treatment to be necessary.
  3. Hyperpigmentation (Red or Brown) and Hypopigmentation (whitening): These side effects have been noted after some treatments and are usually temporary. This usually resolves in 1-3+ months with proper skincare and sun protection. Permanent color change is possible but rarely occurs. 
  4. Micro-Scarring: Advanced Electrolysis sometimes can create a bruise or blister during treatment. Skin will be red and inflamed after treatment. Depending on the level of intensity needed to treat the blemish, a slight uneven skin texture may occur after healing is complete and in rare cases may be permanent.
  5. Infection: Any time the skin barrier is broken, infection can occur. We take steps to minimize infection in your office visit and following proper aftercare will also minimize chances of infection at home.
  6. We HIGHLY recommend attending a check-up appt with your dermatologist BEFORE booking Advanced Electrolysis as we WILL NOT treat skin irregularities that are unidentifiable or suspicious looking.


I authorize Pacific Northwest Electrology LLC to perform Advanced Electrolysis on my person. A series of treatments may be necessary to achieve desired results and some blemishes may need maintenance treatments.


 


I understand the procedure and accept the risks. I hereby release Pacific Northwest Electrology LLC from all liabilities associated with the above indicated procedure for today and future dates. 


 


Photos will be taken before, during and after your procedures. With anonymity these photos may be used for client education, assignment and marketing. 


 


Scabbing usually occurs with treatment! Keep treated areas clean and dry for 24 hrs. Resume gentle skin care until scabs disappear or fall off naturally, NO PICKING!

7-14 days is typical ‘downtime’ for the first part of the healing process (aka the 'crusty phase') and several weeks to several months is typical 'downtime' for the second part of the healing process where pinkness or hyperpigmentation may show.

Mature and thin skin types will have a longer healing process. Compliance with aftercare instructions is crucial for healing, prevention of scarring, prevention of hyper and hypo pigmentation.


 


Dated: May 20, 2025 

 

First Participant's Name
First Name*
Last Name*
Phone*
First Participant's Date of Birth*
Date of Birth
First Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
First Participant's Signature*
Second Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Second Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Third Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Third Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Fourth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fourth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Fifth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Fifth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Sixth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Sixth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Seventh Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Seventh Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Eighth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Eighth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Ninth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Ninth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Tenth Participant's Name
First Name*
Last Name*
Participant's Date of Birth*
Date of Birth
Tenth Participant's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
Participant'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*
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.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Last Name*
Phone*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
How did you hear about PNW Electrology?
Please describe what blemishes or areas you would like treated...
Do you have any permanent makeup or tattoos on areas you wish to be treated?*
No
Yes
Are you currently using acids, retinoids, Retin-A or bleaching agents? (Please discontinue use for 1-2 weeks before treatment)*
No
Yes
Have you had any prolonged sun exposure or tanning within the last 4 weeks? (We cannot treat sunburned skin)*
No
Yes
Are you currently using or have you used photo-sensitive medications like Accutane?*
No
Yes
Do you smoke?*
No
Yes
Any advanced skin treatments like chemical peels, microneedling, injections, laser treatments or surgical procedures etc. in the past 4 weeks?*
No
Yes
If YES please describe when and where on the body
Do you get cold sores or fever blisters? (If YES, you may want to discuss using an anti-viral medication with your doctor prior to treatment)*
No
Yes
If YES, when was the last breakout?
Are you pregnant or breastfeeding?*
N/A
Breastfeeding
Pregnant
Any allergies or sensitivities to skincare products, materials or foods?*
No
Yes
​If YES, please list
Do you have any medical conditions or autoimmune disorders?*
No
Yes
If YES please describe
Any upcoming medical procedures or advanced skin treatments?*
No
Yes
Current Medications
Date of last full body skin check:
Did the doctor advise you to take any precautions?:*
No
Yes
If YES Explain:
Any history of skin cancer?*
No
Yes
If YES, please explain
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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