Consent and Contraindications Verification Form
The Consent and Contraindications Verification Form is an essential document that must be completed by the client before undergoing the procedure. In this form, the client provides informed consent for the procedure while also supplying detailed information regarding their health status and potential contraindications. The purpose of this document is to ensure the client's safety and to protect the legal integrity of the procedure provider.
Name
Last name
Phone number
E-mail
Date of birth
What area are you planning to have your next electroepilation procedure on?
Choose a treatment area
We'll send you the rules of skin care before and after the procedure
Intimate electroepilation
Body electroepilation
Electroepilation on the face
Underarm electroepilation
Health information
Are you taking any medications?
Yes
No
If so, which ones?
Pregnancy
Yes
No
I'm a man
Presence of implants
Yes
No
Menopause
Yes
No
I'm a man
Presence of a pacemaker
Yes
No
Presence of intrauterine device (IUD) / braces / piercing
Yes
No
Infectious/viral diseases (hepatitis, herpes, etc.)
Illnesses now
Gynecological
Yes
No
Cancer
Yes
No
Skin diseases
Yes
No
Remission after cancer
Yes
No
Fungal diseases
Yes
No
Thrombophlebitis and varicose veins
Yes
No
Enlargement of lymph nodes
Yes
No
Diseases of the endocrine system
Yes
No
Diseases of the cardiovascular system
Yes
No
Gastrointestinal diseases
Yes
No
Diseases of the urogenital system
Yes
No
Diseases of the musculoskeletal system
Yes
No
Diseases of the nervous system
Yes
No
Any injuries
Yes
No
If you answered yes to the questions above, please write more about the disease here
How are you feeling at the moment?
Great
Satisfactory
Bad
Bad habits
Allergic reactions
to cosmetics
to metal
to latex
to drugs
Others
No
General Information
What depilation/epilation method have you used before?
Have you done electroepilation before?
Yes
No
If yes, how many procedures have been done and with what interval? Date of the last electroepilation:
Have you used anesthesia before, for example, during dental treatment or other cosmetic procedures? If so, what type of anesthesia was administered?
Do you have a tendency to develop scars on your skin?
No
Yes
Not sure
I, the aforementioned signatory, affirm that I have honestly answered questions about my health status.
That I am aware of all contraindications, home care and possible complications. I confirm that I have understood everything and release the salon, its employees and superiors from responsibility for the result of the procedure.
I agree: photo/video documentation is required to record the procedure's effect. Without consent, the procedure will not be conducted.
Oświadczam, że zapoznałem/-am się z Regulaminem i Polityką Prywatności serwisu internetowego www.elektroepilacja.pl oraz akceptuję ich treść.
Date of filling out the form
How did you hear about us?
Instagram Username
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