Electrolysis Medical History Form

Today's Date*

Your Name*

Your Date of Birth*

Referred By:*

Your Address*

Street Address Address Line 2 City State ZIP Code

Your Email*

Primary Phone Number*

Mobile Phone Number*

Occupation*

Have you had previous electrolysis?*

Yes
No

Please check all areas you would like to have treated:*

Upper lip
Chin / Neck
Eyebrows
Sideburns
Underarms
Bikini
Hands/Feet

Please check all conditions you are currently being treated for:*

Please tell us the ways in which you currently try to remove hair. Check all that apply:*

Previous electrolysis treatments
Tweezed
Shaved
Waxed
Previous laser treatment
Depilatory
Family hostory of excessive hair growth
None of the Above

List all medications you are presently taking:*

List all topical medications, creams or ointments you may be using:*

I certify that the preceding medical, medication and personal history statements are true and correct. I am aware that it is my responsibility to inform the doctor or other health professionals of my current medical or health conditions and to update this history. A current medical history is essential for the caregiver to execute appropriate treatment.

When you select the button below, you will be taken to a screen to sign this document electronically. If you are unfamiliar with electronic signatures, please watch this short video.

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