Electrolysis Client Consultation Mobile App

Included Fields

Customize to add, remove, or edit any of the fields below.

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  Name

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  Date

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  Address

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  D.

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  Phone#

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  Email

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  How did you hear about us?

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  Emergency contact – name & phone number

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  What area(s) are you interested in treating today?

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  How are you currently treating the hair growth?

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  Have you previously had electrolysis treatments?

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  If yes, when was the last treatment and what area(s) were treated?

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  Did you have any concerns or problems with your treatments?

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  If yes, please explain

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  Have you taken Accutane within the last 6 months?

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  If yes, when did you start?

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  When did you stop?

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  Do you have any of the following medical conditions?

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  Do you have any of the following medical conditions?

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  Please list any other medical conditions

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  Do you have any allergies to the following?

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  Please list any other allergies

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  Are you currently under the care of a physician or dermatologist?

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  If yes, please explain

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  I am aware that electrolysis does involve a series of treatments.

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  It is important to stay on a regular schedule due to the cycle in which the hair grows, between t...

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  Please read and initial the following statements to better understand how the electrolysis proced...

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  Electrolysis is a medically approved method of permanent hair removal.

• ...and More!