NOTE: When submitting minor updates to an existing profile, please enter “NC” (No Change) in any fields that do not require revision. The webmaster will apply only the updated details.

Do you want your Member Profile visible to the public? *

Yes - Please make my Member Profile public

No - Please make my Member Profile private

Name *

First Name

Last Name

Pronouns

License / Certification *

CPE

License Number *

Are you currently accepting new clients? *

Yes

I have a wait list

Would you like to be considered for the "Featured Electrologist" on the homepage? *

The Featured Electrologist will change from time to time, priority will be given to providers that are accepting new clients

Yes

Company Name

Website or Social Media Profile

http://

Email *

Phone Number / Text *

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address *

*If different from business address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Hours

(also note if you offer weekend hours)

Modalities *

Galvanic

Thermolysis

Blend

Areas Treated *

ALL

ALL, Other than GRS Prep

Specific Areas Only (Please detail below)

Specific Areas Treated

Specialty

List any specialties you have (e.g. melanated skin, scar tissue, tattooed areas, GCS prep, etc)

Do you accept insurance? *

Yes

If you do accept insurance, please list the insurance providers you work with

Bio *DON'T SKIP THIS!*

Website visitors can search for electrologists using any terms that are important to them, but you'll only show up in those searches if the key words are included in your bio. E.G. weekend hours, trans ally, body positive, menopause, etc.

Information NOT visible to public?

Is there info you want excluded from your public Member Profile? e.g. e-mail, address, etc

Mentorship

Be a Mentor: I am available to mentor new electrologists (via phone, email, etc).

Find a Mentor: I am a newer electrologist that would like to be paired with a mentor.

Thank you!