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148 Linden Street Suite B2, Wellesley, MA 02482
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617-913-2373
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617-913-2373
About
Services
Electrolysis
Microneedling
Advanced Aesthetics
Customized Facials
Professional Exfoliation
Microdermabrasion
Brow & Lash Tinting
Waxing
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Electrolysis Client History Form
Please enable JavaScript in your browser to complete this form.
Legal Name
*
Email
*
Preferred Name
Pronoun
Date of Birth
*
Street Address
City
State
Zip
How Referred
Previous Electrolysis
Date Last Treated
Area(s)
Method(s) of Temporary Removal
Area(s)
Laser Hair Removal
Area(s)
Dates
Are you under doctor's care?
Recent Surgery or Injury
Past Medications
Present Medications
Pregnant?
If yes, due date:
Regular periods
Select option
Yes
No
Over/In menopause
Select option
Yes
No
Hysterectomy
Select option
Yes
No
Birth Control
Select option
Yes
No
Metal Implant / Copper IUD
Select option
Yes
No
Please select if you've ever had any of the following:
Heart Condition
Hepatitis
Coagulation Problem
Cancer Treatment
Pertinent Allergy
Pacemaker
Diabetes
Keloids
Acne
Herpes VII
If selected yes for any of the above, please specify if it's terminated or continued:
If selected "Hepatitis", please specify the type.
Location of hair
Hairline
Back of neck
Eyebrow
Sideburns
Cheeks
Nose
Ears
Lip
Chin
Hands
Feet
Chest
Breast
Shoulders
Back
Underarm
Arm
Abdomen
Bikini
Thigh
Lower leg
Toes
Comments for any of the above
Please enter your name to sign this form
*
I understand that electrolysis/thermolysis is not immediately permanent and that a series of treatments is necessary to achieve permanent hair removal. I understand the success of the treatments depends largely on my cooperation with my treatment schedule, and recommendations made by the electrologist. I agree to inform the technician of any changes in my skin after treatment, as well as, any changes in my general health.
Date
*
History taken by
Please read Cancelation Policy and enter your name to sign it
*
Your appointment is very important to us, and it is reserved especially for you. We understand that sometimes schedules adjustments are necessary; therefore, we respectfully request a 48-hour notice for cancellation. Since the services are reserved for you personally, all no shows and late cancellations are subject to a full charge (100%) of the original appointment.
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