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Electrolysis Hair Removal Intake Form

Personal Information

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Have you had laser hair removal or electrolysis in the past?
Did you have any reaction?
Have you had any of the following hair removal treatments in the last 6 months?
Fitzpatrick Skin Type (Please check which one best describes you)
Do you have any of the following skin disorders?
Do you have any allergies? (Latex, Topical Creams, etc.)
Have you ever had problems with your skin healing?
Have you ever had sensitivity to sunlight?
Have you been treated for of the following medical conditions?
Are you currently on any medications
Are you currently using or have ever used Accutane?
Are you currently using or have ever used Rambazole?
Are you currently using or have ever used Absorica?
Are you currently pregnant or breastfeeding?
Are you pregnant or trying to fall pregnant?
By signing below, you agree to the following: I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes to the information listed on all pages of this intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward the technician and Summer & Co. The cometic Tattoo Studio for any injury or damages incurred due to any misrepresentation of my health history.

Electrolysis Hair Removal Consent

Electrolysis treatments are a form of electrical epilation where a wire filament (needle) is inserted into the hair follicle and a minimal amount of current is delivered to the root of the hair to destroy it through a variety of modalities. All modalities will treat only the offending hair follicle, making this a non-invasive and more direct route to target unwanted hair.


Galvanic Electrolysis - Galvanic electrolysis is the oldest type of hair removal. The direct current used is extremely effective but very slow. It creates a chemical change in the follicle to destroy the root.


Thermolysis Electrolysis - Thermolysis uses shortwave radio-frequency or alternating current (AC). Thermolysis causes the water molecule in your hair to rapidly vibrate, which produces heat. When enough heat is created, thermolysis damages the cells which causes hair growth.


Blend Electrolysis - True to its name, the blend combines both galvanic and thermolysis methods in one treatment. If one type of electrolysis doesn’t kill your unwanted hair the other will.


What To Expect

Our hair is constantly changing from several factors that make us who we are, it’s in our DNA. It is the diversity that makes proper hair removal through electrolysis a process. As our body reacts to different situations such as hormones, medications, weight, and even our genes, our hair growth patterns change and may activate dormant hair follicles. The complex nature of hair growth controls the number of sessions required to reach your personal preference for hair removal. Generally, electrolysis is typically noticeable within three months and can take up to 12+ months for complete and permanent results. We offer sessions from five minutes to an hour and recommend a weekly schedule to treat the follicle right when it emerges and at the optimal time for optimal reaction. Our goal is to see this process through to ensure complete satisfaction. Each individual has a different tolerance level, and that is taken into account. Modern electrolysis methods can be described as causing a tingling or warming sensation, Topical desensitising cream can be applied to help ease the sensation. After your treatment, it is common to experience redness or swelling, both of which are usually short-lived. These are both natural reactions from the stimulus applied to the follicle and can be eased with the use of an ice pack and witch hazel. To prevent any additional reactions, it is critical that you inform us of any medical conditions, medication, supplements, lotions, and oils.


I understand that the treatment is not guaranteed due to risks of complications, both known and unknown to the technician and myself. I understand that the results are reliant on the accuracy of the information I have provided Summer & Co. The Cosmetic Tattooing Studio regarding my medical history and my adherence to proper before and aftercare. I understand that possible side effects may include, but are not limited to Inflammation of the hair follicle, edema (swelling), purpura (bruising), and redness directly after treatment. I understand that the frequency and longevity of treatments are determined solely by my body’s natural hair growth and therefore not predetermined. I acknowledge that I read, understand, and accept the terms above in regard to electrolysis hair removal treatment. I hereby consent to and authorise Summer & Co. The Cosmetic Tattoo Studio to perform electrolysis hair removal treatments and related before and after treatment services on me.

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