Intake Form

Please note:  Charlene is no longer accepting NEW patients.  If you schedule a new appointment you must do so with Jaimie. Thank you!

New Client Intake Form

Your Name (required)

Your Mailing Address (required)

Your Email (required)

Your Phone Number (required)

Calling Instructions - may we leave voicemails? (required)

Your Birthday - we offer $10 off on your birthday

How Did You Find Out About Us or who were you referred by?

What areas are you concerned with? (required)

Which area is your first priority?

How did you remove the hair in that area? (Examples are tweezing, waxing, hair cream, bleach, laser, etc)

How often were you removing the hair?

How has your skin previously reacted to these methods?

Have you had electrolysis before? (required)

What area(s) did you have treated?

What type of electrolysis did you have? Examples would be shortwave, galvanic/blend (you hold something in your hand)

How did you skin react to previous electrolysis?

Was previous electrolysis successful?

Did you notice a change in volume, texture and color of the hair?

How often were your appointments or how many treatments?

Why did you discontinue the treatment?

Is there anything else you feel we should know about or talk about?