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Hair Removal Consult Questionnaire

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Contact Details

Name:

Date of birth:

Age:

Gender

Female

Male

Address:

City:

Postcode:

State:

Country:

Email:

Work Phone:

Mobile:

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

Additional Comments, Concerns, or Areas To Be Treated:

Medical History

Do you have any other conditions not listed above, including any inflammatory or lympathic conditions? List Here:

Other:

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

Other:

Do you have any allergies to foods or medications?

Yes

No

Allergies:

Have you ever had a sensitivity to:

Aspirin

Hydrocortisone

Latex

Topical Anesthetics

Aesthetics Treatment History

If you marked any treatments above, please list treatment & last treatment date(s) below:

Have you recently tanned (sun/spray/tan bed)?

Yes

No

Do you have sunburn in the treatment area?

No

Yes

Have you ever had any sensitivities or reactions to any prior Laser/IPL/Electrolysis Treatments?

Yes

No

If yes, please describe type of hair reduction treatment used and describe the reaction you experienced:

Agreement:

I affirm the above information is accurate to the best of my knowledge. I acknowledge that Beautiology staff are not responsible for any errors that may occur as a result of any omissions or incorrect information on this form.

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Terms and Conditions

Tick here to confirm your acceptance of these 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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