& Electrolysis
Client Information and Medical History
In order to provide you with the most appropriate laser hair removal or skin care treatment, we would appreciate
your time in completing the following questionnaire. All information is strictly confidential.
PERSONAL HISTORY
Today’s Date
Client Name
Date of Birth
Age
Occupation
Home Address
Zip Code
City
Home Phone (
)
State
Work Phone (
)
______
Emergency Contact Name and Phone
How were you referred to us?
MEDICAL HISTORY
Are you currently under the care of a physician? [ ] Yes [ ] No
Are you currently under the care of a dermatologist? [ ] Yes [ ] No
Do you have a history of livedo reticularis, an autoimmune disease, in which the blood vessels are constricted,
or narrowed resulting in mottled discoloration on large areas of the leg or arms? [ ] Yes [ ] No
Do you have a history of erythema igne, which is a persistent skin rash produced by prolonged or repeated
exposure moderately intense heat or infrared irradiation? [ ] Yes [ ] No
Do you have any of the following medical conditions? (Please check all that apply)
[ ] cancer [ ] diabetes [ ] high blood pressure [ ] herpes [ ] arthritis [ ] frequent cold sores
[ ] HIV/AIDS [ ] keloid scarring [ ] skin disease / skin lesions [ ] seizure disorder [ ] hepatitis
[ ] hormone imbalance [ ] thyroid imbalance [ ] blood clotting abnormalities
[ ] any active infection
Do you have any other health problems or medical conditions? Please list:
What oral medications are you presently taking?
Have you ever used Accutane? [ ] Yes [ ] No. If yes, when did you last use it?
What topical medications or creams are you currently using? [ ] RetinA [ ] Hydroquinone [ ] AHA
[ ] others (please list)
Have you ever had laser hair removal? [ ] Yes [ ] No
Have you used any of the following hair removal methods in the past six weeks?
[ ] shaving [ ] waxing [ ] electrolysis [ ] tweezing [ ] threading [ ] depilatories
Have you had any recent tanning or sun exposure that changed the color of your skin? [ ] Yes [ ] No
Have you recently used any self-tanning lotions or treatments? [ ] Yes [ ] No
Do you form thick or raised scars from cuts or burns? [ ] Yes [ ] No
Do you have hyperpigmentation (darkening of the skin) or hypo pigmentation (lightening of the skin) or marks
after physical trauma? [ ] Yes [ ] No, if yes please describe
___________________
Allergies
Have you ever had an allergic reaction to any of the following? (Please check all that apply and
describe the reaction you experienced.) [ ] food [ ] latex [ ] cosmetics [ ] aspirin [ ] lidocaine
[ ] hydrocortisone [ ] hydroquinone or skin bleaching agents [ ] others:
______
For our Female clients:
Are you pregnant or trying to become pregnant? [ ] Yes [ ] No
Are you using contraception? [ ] Yes [ ] No
Are you breastfeeding? [ ] Yes [ ] No
Are your periods regular? [ ] Yes [ ] No
Do you bruise easily? [ ] Yes [ ] No
______
Areas needing treatment: (Please circle)
-Abdomen
-Breasts
-Ears
-Legs
-Sideburns
-Arms
-Brows
-Feet (toes)
-Lip
-Thighs
-Back
-Cheeks
-Hairline
-Neck line
-Underarms
-Between Breasts
-Chest
-Hands (fingers)
-Nose
-Other: _________
-Bikini
-Chin
-Jaw line
-Shoulders
I certify that the preceding medical, personal and skin history statements are true and correct. I am aware that
it is my responsibility to inform the technician, esthetician, therapist, doctor or nurse of my current medical or
health conditions and to update this history as a current medical history is essential for the caregiver to execute
appropriate treatment procedures.
Signature
Date
Consent For
& E l ec t ro l y si s
Patient Name:
I understand that the purpose of this procedure is to remove unwanted hair. There are several alternatives to
electrolysis and/or laser treatments including but not limited to shaving, waxing and tweezing or no treatment at
all.
I understand that the possible risks of the procedure include pain, purpura, swelling, redness, bruising, scarring,
blistering, hypo pigmentation, hyper pigmentation, burning, mottling of skin vascularity and pigmentation and
unforeseen complications. Eye injury is possible but unlikely, providing complete eye protection is properly
used throughout laser treatment sessions.
I understand that a single procedure will most likely fail to completely remove all my unwanted hair in the area
treated. Multiple treatments are required. Individual response will vary according to skin types, hair color,
degree of tanning, follow up care, and the body area being treated.
I understand the treatment may be painful, but this is typically manageable without any pain relief medication.
Color changes, such as hyper pigmentation (brown/red discoloration) or hypo pigmentation (skin lightening),
may occur in treated skin. This may take several months to resolve, if at all. Unprotected sun exposure in the
weeks following treatments is contraindicated as it may cause or worsen this condition (laser only). Blistering
of the skin may occur. Scarring happens but is uncommon.
I have been asked at this time whether I have any questions about this procedure and do not. I understand the
procedure, and risks, accept the risks, and request that this procedure be performed on me by the qualified staff
member.
**It is also important that I:
-Shave between treatments (if desired), and do not use any other hair removal alternatives.
-Inform my technician of any changes of new medications I have taken or health changes I am experiencing.
Signature of Patient
Date
Signature of Practitioner
Date
Signature of Witness
Date
Sophia Esthetic Inc.
FITZPATRICK CHART
Genetic Disposition
Score
0
1
2
3
4
What is the color of your
eyes?
Light blue,
Gray, Green
Blue, Gray or
Blue
Green
Dark Brown
Brownish
Black
What is the natural color of
your hair?
Sandy Red
Blond
Chestnut/Dark
Blond
Dark Brown
Black
What is the color of your skin
(non exposed areas)?
Reddish
Very Pale
Pale with Beige
tint
Light Brown
Dark Brown
Do you have freckles on
unexposed areas?
Many
Several
Few
Incidental
none
Total score for Genetic Disposition: _____
Reaction to Sun Exposure
Score
0
1
2
3
4
Painful
What happens when you stay redness,
in the sun too long?
blistering,
peeling
Blistering
followed by
peeling
Burns sometimes
followed by
peeling
Rare burns
Never had
burns
To What degree do you turn
brown?
Hardly or not
at all
Light color
tan
Reasonable tan
Tan very
easy
Turn dark
brown
quickly
Do you turn brown within
several hours after sun
exposure?
Never
Seldom
Sometimes
Often
Always
How does your face react to
the sun?
Very sensitive
Sensitive
Normal
Very
resistant
Never had a
problem
Total score for Reaction to Sun Exposure: _____
Tanning Habits
Score
0
1
2
3
4
When did you last expose
your body to sun (or artificial
sunlamp/tanning cream)?
More than 3
months ago
2-3 months
ago
1-2 months ago
Less than a
month ago
Less than 2
weeks ago
Did you expose the area to
be treated to the sun?
Never
Hardly ever
Sometimes
Often
Always
Total score for Tanning Habits: _____
Skin Type Score
Fitzpatrick Skin Type
0-7
I
8-16
II
17-25
III
25-30
IV
over 30
V-VI
Laser & electrolysis recommendations
Results vary depending on skin, hair, sex, age and many other factors. Average hair loss is
approximately 85% after (6-8 treatments), although a person with hirsutism (excessive hair
growth), and resistant hair may necessitate additional treatments to achieve satisfactory results.
Shaving (laser only)
Be sure to shave the area to be treated very closely before your hair removal session (1-2 days
prior to treatment). This excludes the face, which we will do for you at the time of the treatment.
Hair removal methods
In the month before and between the treatments, do not use depilatory creams, sugar, bleaching
agents, wax, electrolysis, tweezers, or hair extractors. For the face area, please use only scissors
to trim between the treatments.
Underwear & Clothes (laser only)
Wearing pale underwear is recommended for the treatment of the armpits and groin areas. Wear
lose clothing on the day of the appointment to avoid any irritation.
Sun and Tanning (laser only)
Sun exposure or usage of a tanning bed 2 weeks prior and after the treatment, even self-tanning
products (any products that will darken the skin or that will help you retain you suntan)
*If the precautions are NOT respected this may result in hypo pigmentation or hyper
pigmentation* Sun block (SPF 30 or more) may be applied to the area to be treated.
Medication
Discontinue Accutane 1 year prior to the treatment, it should be discontinued for the duration of
your series. Any type of Chemical Peel 2 - 4 weeks prior and after the treatment on the area to
be treated. Retin-A, Renova and Tazorac 2 weeks prior and after to the treatment.
It is important to notify us if there have been any changes in your medication between your
treatments.
Side Effects
I understand that the risks of this procedure include possible pain, infection, scarring, burning,
drug reactions or interactions or unforeseen complications. There is also a risk of mismatch in
the color or the texture of the skin, temporary redness, hive-like reaction or bruising, brownish
skin discoloration, activation of fever blisters (herpes), temporary increase susceptibility to
sunburn or persistent pinkness for months.
If tattooed “permanent” make up or a “decorative” tattoo is in the area to be treated with laser
hair removal, lightening of decorative tattoos, or blackening of makeup tattooing can occur.
After treatment
Avoid irritation to the treated area with rubbing, tight-fitting clothing, hot baths, swimming-pool,
until the redness disappears. Wait at least 24 hours before applying makeup to the treated area.
We suggest avoid using deodorant for 24 hrs- period following your armpit treatment. As well
as using an antiperspirant is not recommended for the 7 day-period following the treatment.
*If the precautions are NOT respected this may result in hypo pigmentation or
hyper pigmentation and other side effects (such as burning, scaring…) *
Laser hair removal (Technician use)
Date
Treatment
#
Region
Intensity
M/S
No sun since 4
weeks & no new
medication
Client
signature
Technician
Signature