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Your Private, Caring, and Compassionate 5-star Electrolysis Sanctuary, Sustainably Serving All of Los Angeles
213 787 4799
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Client Health History Form
Personal Information
Name
*
Email
*
Today's Date
*
MM slash DD slash YYYY
Referred By
Date of Birth
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Cell Phone
*
How would you like ElectroYogi to contact you for appointment reminders, special offers, etc?
*
Email
Phone Call
Text
Areas To Be Treated
Select 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 Questions
What age did unwanted hair growth begin?
Regular menstrual cycle?
Yes
No
Every _____ Days
Select 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 above
What do you believe caused your hair growth (if new/unusual)?
Previous Methods of Hair Removal
Select 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 Electrologist
How 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 removal
Skin 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)
*
Yes
No
Please initial below to confirm previous selection
*
General Health Questions
Current medications
Reason for current medications
Past medications
Reason for past medications
Select 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 allergies
Date of last complete physical
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 here
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.
*
initial here
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 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 72 HOUR CANCELLATION POLICY, AND I AGREE TO PAY IN FULL FOR ANY MISSED OR LAST MINUTE CANCELLED APPOINTMENTS. I AGREE TO PAY 50% OF MY BOOKED TREATMENT TIME IF CANCELED BETWEEN 48-72 HOURS IN ADVANCE, AND I AGREE TO PAY 100% OF MY BOOKED TREATMENT TIME IF CANCELED IN LESS THAN 48 HOURS.
*
initial here
Please upload photos of the areas you need treated.
Drop files here or
Select files
Max. file size: 512 MB.
Patient/client signature
*
Parent/guardian signature for minor
Date
*
MM slash DD slash YYYY
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Email
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Your Private, Caring, and Compassionate 5-star Electrolysis Sanctuary, Sustainably Serving All of Los Angeles
Home
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Services
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Reviews
Sustainability
FAQ
News
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Contact
Book an Appointment
213 787 4799
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