Electrolysis consultation card
Please get in touch for a Free upfront consultation. I also got a Blog explaining most of the frequently asked questions.
I agree to inform immediately, if my body temperature is getting higher than 37°C, develop a cough or loose my sense of taste and smell in the last 24 hrs prior the treatment.
Diabetes, Epilepsy, Heart Condition, History of cancer, High blood pressure, Circular Condition ,
Yes
No
If YES, elaborate more
Contra – indications / not to be treated: Haemophilia Pacemaker Hepatitis/Aida/HIV Pregnancy (Blend below neck) If in the area: Metal pins/plates Skin disorder Bruising/Swelling Recent Scar Tissue Loss of tactical sensation Varicose veins
Yes
No
If YES, elaborate more
Previous Electrolysis Treatments
Yes
No
If YES, elaborate more
Previous Laser/IPL treatment
Yes
No
If YES, elaborate more
How long ago
How Often
Healing rate/reactions
Reason for discontinuing treatment
First Name
Last Name
Email
Phone Number
Address
Please leave instructions for parking. I am caring heavy equipment, so free immediate parking to the property is required.
Please upload a doctors notes, if you have medical condition and require adapting on your treatments
Select a File
Date of birth
I agree to the terms & conditions and I confirm that the information given in this form is true
Date
Your Signature
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