Energist UltraPlus VPL™ System
User Manual
SD1-43 Issue 3 (CCF 296)
96
Hair Removal Consultation Form
Client Number:
Notes:
Client Name:
Date of Treatment:
Operators Name:
Date:
Please answer the following questions:
Natural Hair Colour
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Black
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Brown
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Dark Blonde
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Dark Auburn
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Grey
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Blonde
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Red
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Dark Brown
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Light Brown
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White
Previous Treatment Methods
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Epilation
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Shaving
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Depilatories
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Electrolysis
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Waxing/Sugaring
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Other:
Areas to be treated:
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Abdomen
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Armpits
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Back
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Bikini
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Buttocks
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Cheeks
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Chest
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Chin
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Ears
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Eyebrows
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Feet
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Fingers
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Forearms
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Full Arms
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Full Legs
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Hands
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Lower Legs
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Neck
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Shoulders
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Thighs
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Upper Arms
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Upper Lip
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Other:
Expectations:
1.
What are your realistic goals?
2.
What concerns do you have regarding treatment?
3.
Do you have any questions regarding the treatment procedure?
Client
Signature: Consultant
Signature:
Consultant notes: Is this client suitable for treatment? YES/NO If no, why?
If yes, have you explained: treatment/completed medical history/witness signed consent/addressed any
concerns/explained pre- and post-treatment care procedures?
