Date MM DD YYYY Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Areas interested in treating: * Chin Neck/ Nape Eyebrows Ears Upper Lip Nose Hands/Fingers Toes/Feet Abdominal/Tummy Chest/Breast Cheeks/Sideburns Bikini/ Upper/Inner Thighs Hairline Legs * Select all methods that you have used to remove hair from all areas of the body. Please add date below from the last time method was used: Shaving Waxing/Sugaring Tweezing Cutting Laser Depilatories Threading No Methods * For each method you selected above please add the last date when method was used: Health Questions * Please list any medications you are currently on and reasons for medication: * Select all conditions that apply to you past and current: Cold Sores Allergy to Latex Cancer Diabetes High Blood Pressure Pacemaker Herpes Keloids HIV Current Pregnancy Skin Tags/Moles Hepititis Please list any other conditions below: * Acknowledgement of Information. Please choose "yes" if you agree to the following: * I understand and agree that I have read the pre & post care information listed on the FAQ's page. I agree to follow all post care instructions and agree to notifying Jahnia Nelson with any concerns with healing process. I will not hold Jahnia Nelson or Melt Electrolysis liable for post treatment reactions. Yes No Please intial: * I understand that thermolysis takes a series of treatments 6-24 months (varies) and is necessary to achieve permanent hair removal based on previous temporary methods of hair removal and my own physiological factors. * I understand that providing accurate health information is important to provide safe and effective thermolysis treatments. I acknowledge that all information is accurate to the best of my knowledge. I agree to notify my electrologist with any changes. Yes No *I have read and acknowledged the late cancellation/ no call no show policy Melt Electrolysis has and I agree to pay in full for any missed or last minute cancelled appointments. Yes No Client Signature Thank you and I look forward to working with you!
