Medical History - Body Sculpt Studios / My Bella Spa, LLC.
INTAKE & CONSENT FORM - All information is Private & Confidential
PERSONAL INFORMATION
Full Name
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First Name
Last Name
Phone Number
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
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-
Month
-
Day
Year
Date
How did you hear about us?
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Your INSTAGRAM or FACEBOOK
*
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Are you here because you require post-op care? (IE: you've had cosmetic/plastic surgery)
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Yes
No
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SURGERY INFORMATION
Date of Surgery
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-
Month
-
Day
Year
Date
What type of surgery did you have?
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Did you have liposuction?
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Yes
No
If you answered yes, please list all the areas where you had liposuction.
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Surgeon's Name
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First Name
Last Name
Was your surgeon board certified plastic, cosmetic surgeon, non board certifies plastic surgeon, or other?
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Board Certified Plastic
Cosmetic
Non Board Certified Plastic
Other
If other, please explain (ex: ophthalmologist, OB/GYN, etc):
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Name of Surgical Center
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Surgical Center Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Surgeon’s Website
*
Surgeon’s Instagram
*
Did you have a patient coordinator?
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Yes
No
Patient Coordinator’s Name / CONTACT PERSON at Surgeon’s Office
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Patient Coordinator’s Telephone
*
Did you use a recovery house?
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Yes
No
Name of Recovery House
*
Recovery House Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a seroma?
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Yes
No
Not Sure
If you answered yes, where is your seroma?
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Do you have a surgical drain?
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Yes
No
Not Sure
If you answered yes, where is your surgical drain?
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Do you have stitches?
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Yes
No
Not Sure
If you answered yes, where are your stitches?
*
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POST-OPERATIVE JOURNEY
Do you follow any recovery groups?
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Yes
No
If yes, what recovery groups do you follow?
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MEDICAL HISTORY
Are you 18 years or older and have proof of identification?
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Yes
No
Check all that apply:
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Asthma / Respiratory Condition / Shortness of Breath
Allergies
Cardiac disease
Cancer
Diabetes
Hypertension
Anemia
Epilepsy
Pain
Nausea
Dizziness
Gastrointestinal Issues
Regular Bowel Movements
Thyroid Gland Disfunction
Pregnant or Breastfeeding
Compromised Immune System
Skin Lesions
Metal Plates or Screws in Body
Open Wounds
None of the Above
Other
Please explain any additional information:
Are you currently taking any medication?
*
Yes
No
If yes, what medications are you taking?
*
Have you scheduled a video call with us?
*
Yes
No
Please list any additional concerns:
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Acknowledgements & Consent
Please read each of the following statements carefully.
ACKNOWLEDGEMENT Please Check all & Sign below
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CONSENT FOR SERVICES: I give Consent for the Manual Lymphatic Drainage procedure, Post Operative services, or Body Contouring procedure that I have purchased. I acknowledge that these services are not a substitute for a medical examination or diagnosis and I should see a doctor for any medical concerns I may have. I agree to update the staff of any changes in my health and release all staff and My Bella Spa / Body Sculpt Studios from any liability if I fail to do so.
ACKNOWLEDGEMENT Please Check all & Sign below
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SPA POLICY: 24 hour Cancellation Policy for all appointments. Must cancel before 24 hours to Avoid LOSS OF ENTIRE SESSION. LATE 15 minutes will be charged $25 Late Fee. RESCHEDULING: Multiple Rescheduling will be charged $50 each time. NO-SHOWs will be charged the ENTIRE COST of the Session and will be counted against treatment plan resulting in the loss of the Session. All Services and Deposits are Non- Refundable. There are No Refunds or Exchanges on any Services or Deposits. Refunds will not be issued.
ACKNOWLEDGEMENT Please Check all & Sign below
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ALL SERVICES & SALES ARE FINAL. There are no refunds on any services. No exceptions. All payments are final. Refunds will not be issued. DEPOSITS: There are no refunds on any deposits.No exceptions. All payments are final. Refunds will not be issued.
ACKNOWLEDGEMENT Please Check all & Sign below
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I confirm that all answers on this form are true and correct to the best of my knowledge. I understand that there are no guarantees to the results of this treatment. I understand to achieve maximum results may require several treatments. I understand that temporary hyperpigmentation/hypo pigmentation on rare occasions may occur as a result of the Taping Wrap, Micro-needling or hot / cold treatments, and various other services.
PHOTO ACKNOWLEDGEMENT Please Check all & Sign below
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FACE ALLOWED : I understand photos will be taken for medical purposes to manage my treatment and used for my patient care plan, marketing, educational literature and training purposes. FACE ALLOWED - I agree to allow my face to be shown and my identity to be revealed for medical purposes to be used for my patient care plan, marketing, educational literature and training purposes. I acknowledge that I have a right to change my mind and discontinue authorization at any time by submitting it in writing via email to fatloss@mybellaspa.com
NO FACE: I understand photos will be taken for medical purposes to manage my treatment and used for my patient care plan, marketing, educational literature and training purposes. NO FACE - My face will not be shown, nor any tattoos or identifiable markings or scars revealing my identity. I acknowledge that photos will be taken for medical purposes to manage my Treatment and patient care plan ONLY.
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