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Electrolysis Consultation & 10-minute Trial Intake Form

Date of birth
Month
Day
Year
Select all that apply:
Circle all to be treated:
Circle all that apply:
Skin reactions to previous hair removal methods:
Circle all conditions, past, & present that apply:

ACKNOWLEDGMENT OF INFORMATION

I understand health history information is important to the Electrologist in order to provide with safe and effective electrology treatments.I acknowledge all information given by me is accurate to the best of my knowledge and I agree to update my health history assessment whenever there are changes. I understand that a series of treatments is necessary to achieve permanent hair removal based on my previous temporary method of hair removal, the science of electrology, and my individual physiological factors. I have been advised of the post-treatment healing process and the possible risks related to treatment. I agree to follow all aftercare instructions and to notify the Electrologist or any concerns or difficulty in healing.

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Date
Month
Day
Year
*Request your consultation time below - confirmation will be sent after approval.
March 2026
SunMonTueWedThuFriSat
Week starting Sunday, March 8
Time zone: Coordinated Universal Time (UTC)142 Buffalo Run Rd Shepherdsville KY 40165
Saturday, Mar 14
10:00 AM - 11:00 AM
11:00 AM - 12:00 PM
12:00 PM - 1:00 PM
1:00 PM - 2:00 PM
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