CLIENT HISTORY & CONSENT FORM Name * First Name Last Name Email * TODAY'S DATE * MM DD YYYY REFERRED BY Date OF BIRTH * MM DD YYYY Phone * (###) ### #### How would you like T4T Electrolysis to contact you for appointment reminders, special offers, etc?* * Email Phone Call Text SELECT ALL AREAS TO BE TREATED * HAIRLINE EARS EYEBROWS NOSE UPPER LIP CHEEKS / SIDEBURNS NECK / NAPE OF NECK CHIN CHEST / BREAST SHOULDERS / ARMS / UNDERARMS BACK (UPPER / CENTER / LOWER) HANDS / FINGERS ABDOMEN / TUMMY BOTTOM SURGERY PREP UPPER / INNER THIGHS BUTTOCKS LEG / LOWER LEG FEET / TOES Select ALL methods that you have used, write which areas of the body, add date when last used and how many years total* * Shaving Cutting / Clipping Tweezing Other methods (explain) Waxing. / Sugaring / Threading Laser Light-Based Electrolysis Bleaching Depilatories No methods used For each method selected above, please list the areas of the body, add date when last used and how many years total. * How often do you remove your hair? (select all that apply) * Daily Weekly Monthly Infrequently Skin reactions to previous hair removal methods (select all that apply) * Redness Pigmentation No skin reaction Pimples Ingrown Hair Other Infections Swelling Describe any of the skin reactions in detail so we can choose the best method of electrolysis for your best healing based on your skin. * Permission to photograph area to be treated (used exclusively for T4telectrolysis.com web site before and after photos) * Yes No Please initial below to confirm previous selection Current medications Reason for current medications Past medications Reason for past medication Select all conditions, past and present that apply Acne Cardiovascular disease Allergy to metal High Blood Pressure Hepatitis TB Metal Implants Warts Allergy to Aspirin Breathing Challenges Cold Sores Pigment problems Herpes Keloids Body Piercings Current Pregnancy Allergy to Latex Cancer Diabetes Skin Tags HIV Healing Problems Pacemaker Other conditions or allergies (explain below) Date of last completed physical MM DD YYYY I understand health history information is important to T4T Electrolysis in order to provide me with safe and effective electrolysis 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 over usually 12-24 months (but possibly longer) 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 T4T Electrolysis of any concerns or difficulty in healing. Further, I will not hold T4T Electrolysis or Drew Imondi-Iannuccillo liable for any omissions or post-treatment reactions.* * **I ACKNOWLEDGE THAT T4T Electrolysis HAS A FULL 24 HOUR CANCELLATION POLICY, AND I AGREE TO PAY IN FULL FOR ANY MISSED OR LAST MINUTE CANCELLED APPOINTMENTS** * Patient/client signature * Date MM DD YYYY Thank you! Your form has been submitted. Don’t forget to book your next appointment!
