Name
*
First Name
Last Name
Gender
*
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Alternate Phone
(###)
###
####
Email
*
Emergency Contact Name
*
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Relationship
*
Referral
*
Were you referred by anyone?
If Yes, by whom?
Medications/Implants/Body Mods
Do you take any of the following medications, have any of the following implants,
or have any of the following body modifications?
Please select all that apply
Current Medications
Medical Conditions
Do you suffer from any of the following medical conditions?
Please select all that apply
Allergies
Do you have an allergy to any of the following?
Please select all that apply
Please elaborate on any of the checked items above if necessary
Other Allergies
Skincare/Treatments
Have you undergone any of the following treatments?
Please select all that apply
Tanning/Sun Exposure
*
Please briefly describe your last exposure to the sun, tanning beds, or self tanning devices. How long? How often?
Smoking
*
Do you smoke?
If Yes, how much? How Often? How long have you been a smoker?
If you quit, how long were you a smoker? How much and how often did you smoke when you were smoker?
Cosmetic Surgery
*
Have you had in the past 90 days, or will you have within the next 90 days, cosmetic surgery involving the treatment area(s)?
Hair Growth
*
Have you ever noticed a sudden growth of your hair?
If Yes, when? Where?
Where is the hair you want to remove? (ex: Chin, Neck, Underarm) Please list all areas if more than one is desired.
Temporary Hair Removal
Have you used any of the following temporary hair removal methods?
Please select all that apply.
Permanent Hair Removal Methods
Have you received permanent hair removal treatments (electrolysis)?
Please select all that apply.
Hair Reduction Methods
Have you used any methods of hair reduction?
Please select all that apply.
Number of sessions for Laser/IPL
Is there anything else we should know?
Comments:
Acknowledgment of Hair Removal Information
*
Please check the box below to confirm that you have read, understand, and acknowledge the following terms.:
I understand health history information is important to the Electrologist in order to provide me with safe and effective hair removal treatments.
I declare all information given by me is accurate to the best of my knowledge and I agree to update my health history information when there are changes.
I understand permanent hair removal requires a treatment program which involves a series of treatments based on my previous methods of hair removal, the science of electrology, and my individual physiological factors.
I authorize Modesty Electrology to take and maintain photographs for the purpose of personal records, case history, and references. Your photos are for internal use only and will not be shared with any third party or posted to any social media without further consent.
I release Modesty Electrology, its managers and or employees of all responsibility concerning any damage or incident that may result from my treatment.
Acknowledgment of Cancellation Policy
*
Modesty Electrology has a full 24-hour cancellation policy. For this reason, all requests to reschedule or cancel an appointment require 24 hours prior notice or you (the client) will be subject to charges equal to the value of the scheduled treatment.
