Electrolysis Consent Form

CLIENT INFORMATION

Client Full Name:(Required)

Phone Number:(Required)

Date of Birth:

Email Address:(Required)

MEDICAL HISTORY & HEALTH INFORMATION(Required)

Please check any conditions that apply:

Other Medical History & Health Information:

Are you currently under a physician’s care?(Required)

Yes

If yes, please explain:

Are you currently taking any medications, including Accutane, Retin-A, antibiotics, or blood thinners?(Required)

Yes

If yes, list medications:

Have you previously received electrolysis or laser hair removal treatments?(Required)

Yes

If yes, explain any reactions or complications:

INFORMED CONSENT

I understand that electrolysis is a process of permanent hair removal involving the insertion of a sterile probe into the hair follicle and the application of electrical current.

I acknowledge and understand the following:

Multiple treatments are required to achieve desired results.
The number of treatments required cannot be determined in advance, and will vary based on several factors, such as hair growth, hair type, skin response, hormonal influences, etc.
Treatment outcomes depend on individual factors and will vary based on each client’s unique circumstances.
Temporary side effects may include, but are not limited to, redness, swelling, tenderness, scabbing, skin irritation, and/or pigmentation changes.
There is a possibility of rare adverse reactions including, but not limited to, blistering, infection, and/or scarring.
I have disclosed all known medical conditions and medications that may affect treatment.
I understand that failure to follow the aftercare instructions listed below may increase the risk of complications.
I understand that no guarantees or warranties have been made regarding treatment outcomes.
I understand that treatment fees are non-refundable and that any corrective services or additional treatment may result in additional charges at the sole discretion of Bee Waxed Cosmetics and Grace Dehko.
I understand that by signing this form, I agree to the service fees set by Grace Dehko.

I consent to receiving electrolysis treatments from the electrologist Grace Dehko. (Consent signature on final document )

Clients Initials :(Required)

PHOTO RELEASE (OPTIONAL)

I authorize the use of before-and-after photographs for documentation and/or marketing purposes.

I do NOT authorize the use of my photographs.

Clients Initials :(Required)

LIABILITY RELEASE

I voluntarily consent to electrolysis treatment and release the business Bee Waxed Cosmetics, electrologist Grace Dehko, employees, and affiliates from liability for any known or unknown complications that may result from the procedure, except in cases of gross negligence or misconduct.

I certify that the information I have provided is true and complete to the best of my knowledge.

SIGNATURE

Client Signature:(Required)

Print Name:(Required)

Date:(Required)

MINOR CLIENT / PARENTAL CONSENT

If the client is under 18 years of age, a parent or legal guardian must read and sign below.

I certify that I am the parent or legal guardian of the minor named below. I have read and understand the information contained in this consent form, and I authorize the electrologist Grace Dehko to perform electrolysis treatments on the minor.

I understand that results may vary and that multiple treatments may be required. I acknowledge the side effects associated with electrolysis treatment and consent to treatment on behalf of the minor.

Minor Client Name:(Required)

Minor Date of Birth:(Required)

Parent/Guardian Name:(Required)

Relationship to Minor:(Required)

Parent/Guardian Phone Number:(Required)

Parent/Guardian Signature:(Required)

Date:(Required)

EMERGENCY MEDICAL AUTHORIZATION FOR MINORS

In the event of a medical emergency during treatment, I authorize emergency medical care to be obtained for the minor if deemed necessary.

Parent/Guardian Initials:(Required)