Medical History - Body Sculpt Studio / My Bella Spa, LLC.
INTAKE & CONSENT FORM - All information is Private & Confidential
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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How did you hear about us?
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INSTAGRAM or FACEBOOK
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What type of surgery did you have?
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Did you have liposuction on more than one area? Please list all areas
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Surgery Date
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Surgeon’s Name
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Surgeon’s Address or Surgical Center Address
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Surgeon’s Website
Surgeon’s Instagram
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Patient Coordinator’s Name / CONTACT PERSON at Surgeon’s Office
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Patient Coordinator’s Telephone
NAME & ADDRESS for Recovery House, Hotel or Air BnB
Which recovery groups do you follow to help others restarting for surgery information?
Check all that apply:
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Over 18 years old & have proof of identification
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
Other
PLEASE EXPLAIN ANY ADDITIONAL INFORMATION or IF CHECKED OTHER ABOVE
Are you currently taking any medication?
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Yes
No
Write Medications Here:
Do you have a Seroma? If YES, Where?
Do you have a Surgical Drain? If Yes, please explain
Have you scheduled a VIDEO CALL with us?
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YES
NO
Please list all of your concerns for the VIDEO CALL:
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ACKNOWLEDGEMENT Please Check all & Sign below
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CONSENT FOR SERVICES: I give Consent for the Manual Lymphatic Drainage procedure or 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 Studio from any liability if I failed 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 $50 Cancellation Fee. Last-minute cancellation will be charged $25 cancellation fee to reschedule appointment. No-Shows will be charged $50 Fee and will be counted against treatment plan resulting in a loss of a Session. LATE 15 minutes will be charged $25 Late Fee.
ACKNOWLEDGEMENT Please Check all & Sign below
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ALL SERVICES & SALES ARE FINAL. There are no refunds on any services once session is completed. 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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