Intake Information FormFilling out our New Client Information Form helps us provide you with the best electrology services. Your details allow us to:Customize Your Treatment: Understand your specific needs and preferences.Ensure Efficiency: Streamline your appointments and avoid delays.Enhance Safety: Maintain accurate records for safe and compliant treatments.Thank you for helping us deliver a personalized and effective service! Click here to download a fillable PDF of the intake form. If you choose to download and fill out the form, please bring this completed form with you to your first appointment. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Birthdate Pronouns Emergency Contact Phone (###) ### #### Emergency Contact Name First Name Last Name Relationship to Emergency Contact Area(s) of the body you're interested in treating: May I discreetly photograph the area(s) being treated? Yes No Let's Talk About It If I can photograph your treatment areas, please initial here. Previous methods of hair removal in area(s) being treated: Shaving Waxing Tweezing Creams Lasers Electrology Please give the dates you last tried any of the methods you checked off to the best of your ability. Medical History- Please check all that apply Cancer - note type below Cold sores/fever blisters Congenital adrenal hyperplasia Cushing Syndrome Diabetes 1 Diabetes 2 Difficulty healing Eczema Electronic implants (e.g. pacemaker) Epilepsy/seizures Hemophilia/bleeding disorder Hepatitis - note type below High blood pressure HIV/AIDS Hormone imbalance HSV1 or HSV2 Irregular periods IUD/oral contraceptive use (current) Keloids Metal implants Polycystic Ovarian Syndrome Psoriasis Thyroid imbalance Vitiligo/Leukoderma Use this space for other conditions not listed or to give more information about anything you checked. Do you have any unusual skin conditions? If yes, please specify Has your skin ever developed hyper- or hypo-pigmented spots as a result of irritation, past medical or cosmetic treatments, or illness? Yes No Are you pregnant, breastfeeding, or planning to become pregnant in the near future? Yes No Have you taken Accutane (oral acne medication) within the past year? Yes No If YES, approximate date of last dose of Accutane MM DD YYYY Are you currently using a topical skin prescription such as Retin-A or Tretinoin on the area being treated? Yes No If YES, please specify Approximate date of last application: MM DD YYYY Are you taking any medications that cause blood-thinning or difficulty clotting? Yes No If YES, please specify Are you taking any immunosuppressant medications, including steroids? Yes No If YES, please specify Please list all current medications and supplements (oral and/or topical): Please list any known allergies or sensitivities to medications or topical solutions: Client’s Printed Name Parent/Guardian’s Name If client is a minor. Thank you!
