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Transgender Care
FAQ
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About
Home
Learn More
Services
Transgender Care
FAQ
Permanent Hair Removal in Charlotte NC
Book Now
health history
please fill out and submit this form before your First appointment:
Today's Date:
*
MM
DD
YYYY
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
May we text you?
*
Yes
No
Email
*
Date of Birth
*
MM
DD
YYYY
Areas you want treated:
*
Choose all that apply.
Face/Neck
Arms/Underarms
Genitals
Abdomen
Legs/Feet
Bikini
Back
Other
Indicate previous/current methods of hair removal:
*
Choose all that apply.
Shaving
Tweezing
Threading
Electrolysis
Clipping
Waxing
Laser
Other
None
Skin reactions to previous methods of hair removal:
*
Choose all that apply.
Redness
Pimples
Ingrown hairs
Infection
Pigmentation
Swelling
Other
None
Skin type:
*
Sensitive
Dry
Oily
Other
Unsure
Have you noticed sudden hair growth or skin changes?
*
Yes
No
Explain
General pain tolerance level:
*
Choose one.
Low
Average
High
Medical Conditions:
*
Choose all that apply.
Skin Cancer
Hemophelia
PCOS
Diabetes
HIV/AIDS
Hepatitus
Keloids
Hormone/Endocrine Disorders
Healing Difficulties
Epilepsy Seizures
Cancer/Remission
Thyroid Disorders
High Blood Pressure
Dermatitis/Eczema
Warts (area to be treated)
History of fever blisters/cold sores (area to be treated)
Implants or metal in body?
Other
None of the above.
Please explain if you checked "Other" in the list above:
Are you pregnant?
*
Yes
No
List Medications:
List Allergies:
Please sign this form by typing your name below. By doing so, you assert that the the information you provided above is complete and accurate to the best of your knowledge. Please update this health assessment whenever there are changes.
*
Enter first and last name. (If you are a parent or guardian signing for a minor, enter the minor's name above, at the top of this form, and your name below.)
Are you a parent/guardian signing for a minor?
Yes
No
Thank you for submitting this Health History Form!