Name *

First Name

Last Name

Birthdate

MM

DD

YYYY

Have you ever been waxed? *

Yes

No

Have you ever had Laser/IPL? *

Yes

No

Have you ever had varicose vein treatment? *

Yes

No

Have you ever had Botox injections? *

If yes, the treatment must be postponed until 3 - 4 months after the last Botox injection. Expect 30% less in results due to hair-producing chemical IGI.

Yes

No

Have you ever shaved? *

Yes

No

Do any of the following apply to you? *

Thyroid - Hypo

Thyroid - Hyper

Hirsutism

PCOS (Polycystic Ovary Syndrome)

Pre-menopause

Pregnant

Breastfeeding

Infertility Treatment

Axillary Hyperhidrosis

Allergies

Diabetes

Cancer

Lupus

Eczema

Rosacea

Psoriasis

Pigmentation

Dermatitis

Acne

Anticoagulants

Chronic Medication

Contraception

I have completed this form to the best of my ability and knowledge and agree to inform the technician on any changes in the above information. I have been informed and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatments unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liabilities towards my technician and the employer for any injury or damages incurred due to any misrepresentation of my health history. *

I agree

I confirm that I have read, understand and answered the above questions correctly to the best of my knowledge. I hereby declare that all the information above is true. I understand that I have to follow post treatment / aftercare to achieve optimum results. I hereby give consent for photographs to be taken of the treated areas to assess progress. *

I agree