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Health History Assessment 

Personal Information 

Areas to be Treated

Select all that apply:

Previous Methods of Hair Removal 

Select all hair removal methods you have used:
Select any skin reactions you have experienced with other hair removal methods:

General Health Questions 

Select any that apply:

Acknowledgement of Information 

I understand the health history information is important to the Electrologist in order to provide me with a safe and effective electrology treatment.  I acknowledge all the 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 are 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 read the aftercare treatment and I agree to follow all aftercare instructions.  I will notify the Electrologist of any concerns or difficulty in healing. 

I understand the area to be treated will be photograph. 

Thanks for submitting!

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