Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone (Home)Additional (Cell)Email Note that all the information is necessary to offer you the best service we can offer and to avoid any complications.Have you had a medical history of herpes?YesNoHave you had a medical history of cold sores?YesNoAre you pregnant or nursing?YesNoIf you have answered “yes” to one of the previous questions, we recommend you use anti-viral medication. (use a day before electrolysis treatment and a week after)If you are pregnant or nursing it is impossible to perform this treatment. We strongly recommend rescheduling your appointment for another availability, which will be a safer solution for you. As our body reacts to different situations such as hormones, medications, weight and even our genes, our hair growth pattern changes and may activate dormant hair follicles. The fact that we all have different type of hair makes electrolysis.Consent I do understand that their might be side effects consequent to the treatment including: -Inflammation of the hair follicle -Edema (swelling) -Purpura (bruising)Please check aboveConsent I understand that their may be short term effect of the treatment, that may include the following: - Redness -Inflammation -LighteningPlease check aboveHyper-pigmentation (browning) and Hypo-pigmentation (lightening) are one of the effects of this treatment. It is important to understand that these effects should heal within 3-6 months, but it is necessary to accept that their may be some color changes (in rare cases). It is important to follow post and after care for electrolysis. One of the principal factors are avoiding the sun to assure best results. The color change of the skin may affect the result, because when the color of the skin changes, the level of the treatment must change.Acknowledgement: I understand that the complications that may occur may be unknown and known to myself and to the specialist preforming the procedure. I am aware that the treatment is not guaranteed due to risks of complications, that do no depend from the specialist nor the clinic. I understand that all results related to this treatment depend on the information I have provided IDEAL BODY CLINIC regarding my medical history. I hereby consent to and authorize Ideal Body Clinic to perform electrolysis hair removal treatments and/or procedures preformed that are related to electrolysis (before, during and after)Compliance with the aftercare guidelines is crucial for healing, prevention of scarring, and hyper-pigmentation I acknowledge that I read, understand and accept the terms and liabilities that were mentioned above related to electrolysis hair removal treatment. I have understood all the information given and all questions were answered decently. I understand the procedure and accept the risks related to the electrolyse and all treatment procedure that may be preformed before, during and after the treatment. Please note that all products and services provided are not subject to refund. However, they can be exchanged or be credited the precedingly paid amount or the remaining balance.SignatureDate Date Format: MM slash DD slash YYYY
