ELECTROLYSIS MEDICAL WAIVER FORM
Patient Information (tick which applies)
Select areas to be treated:
Other:
Hormone-Related Questions:
For Females ONLY if you selected Chest/Breast, Chin/Under Chin, Upper/Lower Lip, and/or Upper/Lower abdomen.
SELECT ALL THAT APPLY
Previous Methods of Hair Removal.
Check all that apply.
How long did you use these methods of hair removal?
How often do you remove hair?
Skin reactions to previous hair removal methods. Check all that apply.
Permission to photograph area treated?
Select all conditions, past and present that apply:
Emergency Contact Information
How did you hear about Epitome Beauty?
Acknowledge of Information
I understand health history information is important to the Electrologist in order to provide me with safe and effective electrology treatments. I acknowledge all information given by me is accurate to the best of my knowledge and I agree to update my health history assessment whenever there are changes.
I understand that a series of treatments is necessary to achieve permanent hair removal based on my previous temporary methods of hair removal, the science of electrology, and my individual physiological factors.
I have been advised of the post-treatment healing process; the possible risks related to treatment, I agree to follow all aftercare instructions and to notify the Electrologist of any concerns or difficulty in healing.
(By submitting this form you are acknowledging all the above)
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