EpilSoft Electrolysis Clinic
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Appointment Request Form

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 questionaire and you will be contacted shortly. In the meantime, thank you for your interest.

Name
 * required
Address 1
 * required
Address 2
Town/City
 * required
County
Postcode
 * required
E-mail
 * required
Contact Telephone
 * required
How would you prefer to be contacted?
E-Mail
Telephone
Date of Birth
Number of Children
Occupation
Preferred Appt Date
Preferred Appt Time
Alternative Appt Date
Alternative Appt Time
Area(s) for which you seek electrolysis
What previous methods of hair removal have you used in the area (check all that apply)
Waxing
Tweezing
Shaving/Cutting
Depilatory Creams
Have you used any of the following (check all that apply)
Electrolysis
Laser
IPL
If yes to Electrolysis, Laser or IPL, when was your last treatment
How would you describe the skin and its healing rate in the area to be treated

MEDICAL SECTION

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?:
Diabetes
Epilepsy
Heart Condition
History of Cancer
Circulatory Problems
High Blood Pressure
Haemophillia
Pacemaker
Hepatitis/Aids/HIV
Pregnancy
Allergy to Latex

 

Do You Have Any Of The Following In The Treatment Area?:
Metal Pins or Plates
Skin Disorder
Bruising or Swelling
Recent Scar Tissue
Loss Of Tactile Sensation
Varicose Veins
Name of your GP
GP's contact address
GP's contact telephone
Other Doctor or Consultant's name
Other Dr/Consultant's contact details
Do you give permission for me to contact your GP should I consider it necessary
Yes
No
Medications
How would you describe your general health
Any other comments

If you have any questions, comments or wish to discuss your requirements or a cost-effective treatment plan, please contact me on my mobile:
 
07971 606633
 
or send me an e-mail:

stephanie@epilsoft.co.uk

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