Electrolysis Treatment Consent Form

Secure informed permission from clients ahead of an electrolysis session, covering treatment areas, allergies, prior sessions, and a signature. Made for electrologists, aesthetic clinics, and medical spas.

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Full name

First Name

Last Name

Phone number

Emergency contact name

First Name

Last Name

Emergency contact phone number

Areas to be treated:*

Face Upper lip Chin Underarms Legs Bikini line Back Other

Do you have any known allergies or sensitive skin?

Yes No Not sure

If yes, please describe:

Have you had electrolysis before?

Yes No Not sure

If yes, share the details:

I understand the possible risks and benefits of electrolysis, including effects such as redness, swelling, and discomfort, and my questions have been answered.

I agree I do not agree I have questions

I consent to the treatment and confirm I am over 18 or have a parent's permission.*

I agree I do not agree I have questions

Signature

Sign here

Date

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