About this template
The Electrolysis Client Intake Questionnaire is an essential digital form designed for licensed electrologists, estheticians, and skin care clinics to gather vital medical and skin history before performing permanent hair removal treatments. Thorough intake documentation is critical for identifying potential contraindications—such as hormonal imbalances, recent sun exposure, active skin products, medications, or susceptibility to cold sores—that could impact treatment safety and efficacy.
By utilizing Doc2Form to convert this questionnaire into an easy-to-use Google Form, clinics can seamlessly capture client background details, treatment areas, hair removal history, and required policy acknowledgments before the client arrives. This eliminates messy paper clipboards, streamlines the check-in process, and ensures your practice maintains organized digital client records. Whether you run a dedicated electrolysis studio or a full-service medical spa, this form helps protect your business while delivering a smooth, professional onboarding experience for every new client.
Key features
- Collect complete medical history and skin background before sessions
- Identify treatment contraindications like medications or recent sun exposure
- Document prior hair removal methods and targeted treatment areas
- Secure necessary policy, aftercare, and liability acknowledgments
- Mobile-friendly format for clients to complete easily on their phones
Use cases
New client onboarding at electrolysis studios and permanent hair remo…
New client onboarding at electrolysis studios and permanent hair removal clinics
Pre-treatment medical screening for medical spas and estheticians
Tracking client hair growth patterns and treatment progress across se…
Tracking client hair growth patterns and treatment progress across sessions
Gathering signed treatment policies and cancellation terms
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Email Address (Short answer)Where we can send your appointment confirmations and aftercare instructions.
- Phone Number (Short answer)Best number to reach you regarding your appointment.
- Date of Birth (Date)Used for client identification and age verification.
- Electrolysis Treatment Areas (Checkboxes)Select all areas you would like treated during your sessions.
- Prior Laser or Electrolysis Treatments (Multiple choice)Have you ever received laser hair removal or electrolysis before?
- Prior Treatment Details (Paragraph)If yes, please describe when and what type of treatment you received.
- Are you currently pregnant or breastfeeding? (Multiple choice)Certain hormonal shifts may impact skin sensitivity.
- Do you have a history of cold sores (HSV) in the treatment area? (Multiple choice)Especially relevant for facial electrolysis treatments.
- Recent Sun Exposure or Tanning (Multiple choice)Have you had intentional sun exposure, tanning beds, or self-tanner applied in the last 2 weeks?
- Current Medications and Topical Products (Paragraph)List any prescription medications, retinoids, AHAs/BHAs, or antibiotics used in the last 14 days.
- Medical Conditions & Hormonal Imbalances (Paragraph)Please list any relevant medical conditions, skin disorders, or diagnosed hormonal imbalances (e.g., PCOS).
- Policy & Treatment Acknowledgement (Multiple choice)Please confirm that you understand treatment outcomes can vary and that adherence to aftercare instructions is essential.
- Client Signature (Short answer)Please type your full legal name to serve as your digital signature and confirmation of accurate medical history.
FAQ
Why is a pre-treatment electrolysis questionnaire necessary?
It helps identify medical conditions, medications, or skin sensitivities that could affect the safety or results of the electrolysis procedure, ensuring tailored and safe care.
Can I customize the questions to fit my specific clinic policies?
Yes! Once your form is generated in Google Forms, you can freely edit, add, or remove any questions to align with your practice requirements.
Is this form mobile-friendly for my clients?
Google Forms automatically optimizes layouts for mobile devices, allowing your clients to fill out and submit their intake forms comfortably from their smartphones.
How do I share this form with my clients before their appointment?
You can easily share the Google Form link via email confirmation, text message, or embed it directly on your clinic's website.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.