Electrolysis by Stephanie

Personal Details

Proposed Dates

About The Area To Be Treated

What previous methods of hair removal have you used in the area? (check all that apply)

Have you received any of the following treatments previously? (check all that apply)

Medical Information

Additional information required for treatment:

Information provided will be used to help assess whether treatment can indeed be provided, or whether a referral to your GP will need to be made before treatment can be offered. In most cases treatment can be offered without GP referral.

(note that information provided will be kept in confidence)


Do you suffer from any of the following conditions?

Do You Have Any Of The Following In The Treatment Area?

Conditions:

I understand that should I proceed with treatment, no responsibility can be accepted by the Electrologist for any injury to myself resulting from treatments where incorrect information has been given. I agree to follow the recommended aftercare for this treatment, which is available here. I understand that a minimum of 24hrs notice of cancellation of an appointment is required, otherwise I will be liable for the full cost of the missed appointment.


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Appointment Request

To request an appointment please complete the form below and then click 'Submit'. Please note that it is not obligatory to fully complete the form at this stage, however I will need to ask all the questions contained in the form prior to commencing treatment, and therefore completing it now will reduce the time taken for your first appointment, and may save you an unnecessary journey in the unusual event I am unable to commence treatment, either because of a need to contact your GP or if treatment is contra-indicated. Please also note that all information supplied will be kept in strict confidence, and your GP will not be contacted without your prior consent. Thank you for taking the time to complete the questionnaire and I will contact you as soon as possible. In the meantime, thank you for your interest.