Birthday

How do you prefer to communicate?

Have you received Electrolysis before?

If you have, which modality of electrolysis were you receiving?

Are you currently pregnant or planning to become pregnant?

If I do become pregnant, I agree to notify my practitioner immediately.

Do you have an allergy or sensitivity to:

Do you have:

Are you currently on Hormone Replacement Therapy or any medications to regulate hormones?

Are you working towards balancing your hormones naturally?

Which areas do you wish to treat with Electrolysis?

How do you currently remove hair from the area to be treated?

How often are you currently removing your hair?

Have you received the following in the last two weeks? Estimated times in between electrolysis and other treatments listed below:

Have you been diagnosed with cancer within the last year? (If yes, please contact immediately)

In the last year, have you undergone chemotherapy or radiation? (If yes, please contact immediately.)

I understand Electrolysis is a time-based service. If I arrive late for my appointment, my appointment will end at the allotted time, and I am financially responsible for the appointment time booked. (For example: A 30-minute appointment at 12pm is booked

If I fail to give 24 hours notice, cancel same day, or miss my appointment, I will be held financially responsible for the appointment time booked. I will be invoiced, and I agree to pay the invoice before my next booked appointment.

If I arrive with less than 7 minutes remaining of my allotted time, my electrologist reserves the right to reschedule and I will be held financially responsible for my appointment.

I am aware that it takes a series of treatments to achieve permanent results. My results are dependent upon my consistency and commitment to my appointments.

I have been informed and I am aware that it is normal to break out or scab following my treatments. I am aware that picking my scabs or break outs can result in prolonged healing of the skin and potential scarring.

I understand if I purchase a package, I have 30 days from the date of purchase to request a refund. I will be issued a refund within 30 days for the prorated amount of the package. To receive the package discount, the package must be purchased in full.

Date