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Please fill out
prior to your appointment.
148 Linden Street Suite B2, Wellesley, MA 02482
Brow & Lash Tinting
Schedule appt ⭢
Electrolysis Client History Form
Date of Birth
Date Last Treated
Method(s) of Temporary Removal
Laser Hair Removal
Are you under doctor's care?
Recent Surgery or Injury
If yes, due date:
Metal Implant / Copper IUD
Please select if you've ever had any of the following:
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
Back of neck
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.
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.