Client Intake Form Contact & Referral Preferred Name * First Name Last Name Is Name Legal * Yes No Birth Date * MM DD YYYY Email * Phone * (###) ### #### Referred By First Name Last Name Preferred Contact Method * Text Email Treatment Factors Allergies * Yes No Bleed Easily * Yes No Bruise Easily * Yes No Hemophilia * Yes No Copper IUD * Yes No HIV/AIDS * Yes No Hepatitis * Yes No Endocrine Disorder * Including transsexual Yes No Endocrine Disorder Intersex * Yes No Intersex Cancer Treatment * Yes No Cancer Treatment Hormonal Medication * Such as birth control Yes No Hormonal Medication Pregnant * Yes No Diabetes * Yes No Cold Sores/HSV * Yes No Cold Sores/HSV Hepatitis * Yes No Hepatitis If yes, type A B C PCOS * Yes No Hysterectomy * Or other surgery with endocrine significance Yes No Hysterectomy Implants * metal or silicone Yes No Implants Irregular Menstrual Cycle * Yes No Irregular Menstrual Cycle Other * Yes No Other Medication * List all medication regularly taken, including OTC & PRN Treatment Planning Areas To Be Treated * Arms Back Bikini/Groin Buttocks Chest Ears Face: Cheeks Face: Chin Face: Eyebrows Face: Jaw Face: Lip Feet/Toes Fingers/Hands Genitalia Neck: Front Neck: Back Nipples Shoulders Stomach Legs Other Hair Removal Methods * Select any methods you use regularly Bleaching Threading Shaving Depilatory Cream Tweezing Waxing/Sugaring Other Epilation Other Hair Removal Methods If 'other' please describe Skin Features * Select all that apply Blemishes Pitting Dehydration Sensitive Freckling/pigmentation prone Scarring Oily/blocked Use of retinoids Blushing/rosacea Other Skin Features If 'other' please describe Has Received Electrolysis In The Past * Yes No Areas Previously Treated If applicable... Arms Back Bikini/Groin Buttocks Chest Ears Face: Cheeks Face: Chin Face: Eyebrows Face: Jaw Face: Lip Feet/Toes Fingers/Hands Genitalia Neck: Front Neck: Back Nipples Shoulders Stomach Legs Other Prev Treatment Times If applicable... Approximate Number of Treatments per Area If applicable... Reason for Ceasing Treatment If applicable... Quality of Prior Electrolysis If applicable... My Results Were Total & Permanent Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
