Hair Removal Consult Questionnaire

Contact Details

Name:
Date of birth:
Age:
Gender
Address:
City:
Postcode:
State:
Country:
Email:
Work Phone:
Mobile:

How did you hear about this clinic?

Please check the areas you are interested in having treated for hair reduction or removal:

Face/Head/Neck:
Body:

What is your natural hair color in area(s) you are interested in having treated? (Check all that apply)
What is your hair quality in area(s) you are interested in having treated? (Check all that apply):
Additional Comments, Concerns, or Areas To Be Treated:

Medical History

Please check if you are affected by, or have any of the following:
Do you have any other conditions not listed above, including any inflammatory or lympathic conditions? List Here:

Do you have any of the following?
Hormone Related Conditions (Women)
Other:

Please list all the medications you are currently taking (including herbal, over the counter, topical, oral and supplemental):

Check all photosenstive herbs/meds you use:
Other:
Do you have any allergies to foods or medications?
Allergies:
Have you ever had a sensitivity to:

Aesthetics Treatment History

Have you recently had/used any of the following
If you marked any treatments above, please list treatment & last treatment date(s) below:
Have you recently tanned (sun/spray/tan bed)?
Do you have sunburn in the treatment area?
What is your current hair removal system?
How often do you remove your hair?
Skin reactions to previous hair removal methods (check all that apply)
Have you ever had any sensitivities or reactions to any prior Laser/IPL/Electrolysis Treatments?
If yes, please describe type of hair reduction treatment used and describe the reaction you experienced:

Agreement:



Terms and Conditions

Cancellations Policy:

Beautiology requires 48 hours notice of cancellations of appointments.

Cancellations of 24 hours notice will be charged at 50% of the treatment value.

No-shows, and less than 24 hours notice will be charged at 100% of the treatment value.

 

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Auckland, New Zealand