Ace Electrolysis Permanent Hair Removal Medical Consultation/Consent Form Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* MM slash DD slash YYYY Age*Referred By Instructions for Contact Email* Phone*Text Okay?* Yes No Allergies* Yes No List Allergies List all topical steroids and antibiotics, if any: Currently taking or have used any of these products in the last 6 months?Isotretinoin (i.e. Amnesteem, Claravis, Myorisan)?* Yes No Topical retinoids (i.e. Retin-A Micro, Retin-A)?* Yes No Topical alpha hydroxy acids/beta hydroxy acids?* Yes No Are you pregnant or plan on becoming pregnant?* Yes No Do you have any body piercings?* Yes No Please list location of piercings:* Medical HistoryDiabetes* Yes No More information (Diabetes)Slow healing* Yes No More information (slow healing)High/low blood pressure* Yes No More information (high/low blood pressure)Infectious disease* Yes No HIV* Yes No Hepatitis* Yes No Connective tissue disorder* Yes No More information (Connective tissue disorder)Epilepsy* Yes No Asthma* Yes No Circulatory disorder* Yes No Implanted intrauterine device (IUD)* Yes No Hormonal imbalance* Yes No More information (hormone imbalance)PCOS (Polycystic Ovarian Syndrome)* Yes No Thyroid condition* Yes No Menopause symptoms* Yes No More information (menopause symptoms)Hysterectomy/Oophorectomy* Yes No Cardiac abnormalities* Yes No More information (cardiac abnormalities)Pacemaker or internal defibrillator* Yes No Deep Brain Stimulator (DBS) Implant* Yes No Metal implants such as pins, ,rods, or plates* Yes No Location of metal implantsCarcinoma* Yes No Psoriasis* Yes No Herpes Simplex* Yes No More information (Herpes Simplex)Skin Assessment* Asian Black/African Caucasian Hispanic/Latino Native American Indian Previous electrolysis?* Yes No How long?* Areas treated:* Previous laser?* Yes No How long?* Areas treated:* Other forms of hair removal attempted:* Tweezing Waxing Sugaring Depilatory cream Other None Please specify other method of hair removal attempted:* How long? Any unusual skin reactions to previous hair removal methods?* Yes No More information (unusual skin reactions to previous hair removal methods)Select all areas interested in treating:* Face Chin/Neck Upper Lip Back Chest Underarms Legs Bikini Other Please specify other area(s) interested in treating:* Acknowledgement of Information*1. I have given accurate health history and agree to update my information whenever there are changes. 2. I have been given an explanation of the electrolysis process and understand that a series of treatments is necessary to achieve permanent hair removal. 3. I understand that the time it takes will depend on my adhering to the recommended treatment schedule, my individual physiological factors, the methods of hair removal used in the past, and the science of electrology. 4. I understand that there will be a post-treatment healing process and there are possible risks related to treatment. 5. I agree to follow all aftercare instructions and to notify the electrologist if I have questions, concerns, or difficulty in healing. 6. I understand the electrologist may take photos to document skin and hair conditions. 7. I understand that there will be a charge for missed appointments and for appointments that are canceled with less than 24 hours notice. 8. I release voluntarily this establishment of all responsibility concerning any damage or incident that may result from treatment. I acknowledge and agree to the above.Signature*Today's Date* MM slash DD slash YYYY SignatureParent or guardian if patient is under 18Today's Date MM slash DD slash YYYY CAPTCHA
