Personal InformationName*Email* Today's Date* Date Format: MM slash DD slash YYYY Referred ByDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Cell Phone*How would you like ElectroYogi to contact you for appointment reminders, special offers, etc?* Email Phone Call Text Areas To Be TreatedSelect all areas to be treated* HAIRLINE NECK / NAPE OF NECK ABDOMEN / TUMMY EARS CHIN BIKINI (PARTIAL / BRAZILIAN) EYEBROWS CHEST / BREAST UPPER / INNER THIGHS NOSE SHOULDERS / ARMS / UNDERARMS BUTTOCKS UPPER LIP BACK (UPPER / CENTER / LOWER) LEG / LOWER LEG CHEEKS / SIDEBURNS HANDS / FINGERS FEET / TOES Hormone-Related QuestionsWhat age did unwanted hair growth begin?Regular menstrual cycle?YesNoEvery _____ DaysSelect all that apply Fertility challenges Hormone/Endocrine disorder Scalp hair loss Weight gain/loss Family history of similar hair growth Irregular menses Acne Hysterectomy or Menopause Eating disorder Other hormone challenges or explanation of aboveWhat do you believe caused your hair growth (if new/unusual)?Previous Methods of Hair RemovalSelect ALL methods that you have used, write which areas of the body, add date when last used and how many years total* Shaving Waxing/Sugaring/Threading Bleaching Cutting/Clipping Laser Depilatories Tweezing Light-Based No methods used Other methods (explain) Electrolysis If Other method is selected, please list below*For each method selected above, please list the areas of the body, add date when last used and how many years total.*Name of previous ElectrologistHow often do you remove your hair? (select all that apply)* Daily Weekly Monthly Infrequently Please take a moment to describe your reactions and results to laser hair removalSkin reactions to previous hair removal methods (select all that apply)* Redness Pimples Infections Pigmentation Ingrown hair Swelling No skin reaction Other 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 ElectroYogi.com web site before and after photos)*YesNoPlease initial below to confirm previous selection*General Health QuestionsCurrent medicationsReason for current medicationsPast medicationsReason for past medicationsSelect all conditions, past and present that apply Acne Allergy to Aspirin Allergy to Latex Cardiovascular disease Breathing Challenges Cancer Allergy to Metal Cold Sores Diabetes High Blood Pressure Pigment Problems Skin Tags Hepatitis Herpes HIV TB Keloids Healing Problems Metal Implants Body Piercings Pacemaker Warts Current Pregnancy Other Conditions or Allergies (explain below) Please explain any other conditions or allergiesDate of last complete physical Date Format: MM slash DD slash YYYY Acknowledgment of Information(please initial each paragraph and sign at bottom of page)I understand health history information is important to the ElectroYogi 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.*initial hereI 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.*initial hereI 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 ElectroYogi of any concerns or difficulty in healing. Further, I will not hold ElectroYogi or Nicole Policicchio liable for any omissions or post-treatment reactions.*initial here**I ACKNOWLEDGE THAT ELECTROYOGI HAS A FULL 24 HOUR CANCELLATION POLICY, AND I AGREE TO PAY IN FULL FOR ANY MISSED OR LAST MINUTE CANCELLED APPOINTMENTS***initial herePatient/client signature*Parent/guardian signature for minorDate* Date Format: MM slash DD slash YYYY
