Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Areas to be Treated:

Check all that apply.

Upper Lip

Chin / Neck

Sideburns

Hairline

Eyebrows

Ears

Back

Chest

Bikini

Legs

Underarms

Skin Blemishes Interested In Removing:

Check all that apply.

Skin Tags

Cherry Angiomas

Spider Veins

Milia

Seborrheic Keratoses

Have you had previous electrolysis treatments? *

Yes

No

Hair Removal Methods Currently Using:

Check all that apply.

Tweezing

Waxing

Shaving

Threading

Depilatory

Cutting

Bleaching

Laser

Do you have any of the following signs in the area to be treated?

Check all that apply.

Bruising

Swelling

Peeling

Dryness

Oiliness

Pigment Changes

Do you have any of the following lesions in the area to be treated?

Check all that apply.

Acne

Eczema

Dermatitus

Psoriasis

Keloids

Skin Cancer

Fever Blisters / Cold Sores

Moles

Ingrown Hairs

Check if you ever had allergies to:

Check all that apply.

Medicines

Soaps

Cosmetics

Sun

Food

Plants

Other

Check if you have any of the following conditions.

Check all that apply.

Bleeding Problems

Diabetes

High Blood Pressure

Epilepsy

Vertigo

Cancer

HIV Positive

Thyroid Problems

PCOS

Herpes / Cold Sores

Hepatitus

Pacemaker

Cochlear Implant

Currently Pregnant

Metal Implants in the Body

Are you currently using Retin A? *

Yes

No

Have you had a recent collagen or Botox Injection? *

Yes

No

Office Policies *

Payment is due in full via cash, debit/credit card, or Venmo at the end of each appointment. We request minimum of 24 hours notice to cancel or change your appointments. Failing to give us 24 hours notice will result in a charge of $20 or 50% of the scheduled service, whichever is greater. No-shows will be charged 100% of the service price. Any outstanding balance must be paid before you can book another appointment. A parent must accompany clients under 18 during the consultation. Clients under 16 must have a parent present during all treatment sessions. Do you agree to these terms?

Yes

No

Today's Date *

MM

DD

YYYY