form - Electric Beauty Electrolysis

Client History

Photographs to show progress:

Yes

No

Photograph privacy requested:

Yes

No

Name

First

Last

Date of Birth*

Phone:

Email address*

Have you noticed sudden hair growth or changes?

Yes

No

Explain:

I understand health history is important to the electrolysis in order to provide me with safe and effective treatments. i acknowledge all the 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 have been advised and agree to follow all aftercare instructions and to notify the electrologist of any difficulty in healing.

Client

Signature of Minor

Parent/Guardian

Date

I understand that the treatment is not guaranteed due to risks of complications, both known and unknown to the technician and myself.

I understand that the results are relient on the accuracy of information I have provided Electric Beauty Electrologist reguarding my medical hostory and my adherence to proper before and after care.

I understand that possible side effects may include, but are not limited to:

Inflammation of the hair follicle
Edema (swelling)
Purpura (bruising)
Redness directly after treatment
Change in pigmentation
Small blisters and/or pinpoint bleeding (possible scarring if these are aggravated)

I understand that the frequency and lovgevity of treatments is determeined solely by my body's natural hair growth and therefore not predetermined.

I acknowledge that I read, understand, and accept the terms above reguarding electrolysis hair removal treatment. I hearby consent to and authorize Electric Beauty Electrologist to perform electrolysis hair removal treatments and related before and after treatment services on me

Client Signature:

Date

Client History Form

Client History