Skip to main content

Electrolysis Medical History Form

If you are an electrolysis patient at Berkshire Hair Removal, please fill out this confidential medical history form in just a few minutes prior to your first visit with us.

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • 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.