Ultrasound Cavitation/RF Intake Form
Street Address Line 2
State / Province
Postal / Zip Code
Emergency Contact Name
Emergency Contact Phone Number
Waist (love handles)
Front of Thighs
Back of Thighs
Check if YES to any of these Questions
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have a current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloids?
Do you have any kind of heart trouble?
Do you have any current infections?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, or liver disease?
Any other medical conditions?
If you checked any of the above questions you may not be eligible for treatment. Please explain "YES" answers here:
Are you presently taking any medications?
Are you allergic to any foods or medication?
Please explain any other current medical conditions.
Are you taking any vitamins/supplements?
Are you presently under physicians care?
For What? (if nothing put NA)
Are you taking recreational drugs?
Family or Primary physician name
Physician's phone number
Should be Empty: