Intake and Evaluation Form

Name

First NameLast Name

Age

Date of birth

sex

gender pronoun

Address

Address line 2

CityState

Postal Code

Mobile Number

Area CodePhone Number

Email

example@example.com

occupation (important for care customization)

EMERGENCY CONTACT

Name

EMERGENCY CONTACT PHONE NUMBER

Area CodePhone Number

DID/WILL YOU HAVE SURGERY OR A COSMETIC SURGICAL PROCEDURE?

If so what procedures? Please be thorough and lIst all areas

WHAT SERVICES ARE YOU INTERESTED IN?

GOALS

Favorite music artist/Genre

How did you hear about us?

Whats your IG or FB? Only lIst one or the other

Please check all that currently apply.

Please list any other current health conditions or surgeries not mentioned above. IF NONE TYPE N/A

List ALL your medications. If nonE. Include any VitamIns, herbs, supplements. please type N/a.

Would you know if your conditions require a doctor to agree with your required treatment?

Please give a full list of allergies or sensitivities:Type N/A if no allergies

ARE YOU ON BIRTH CONTROL? IF SO, WHAT KIND. IF NOT, N/A

At time of completing this form, what is your health status?

What was/is the date of your Surgery?

Surgeon's name and number

Surgeon Name

Phone Number

Did you receive Post op instructions

Drains/wounds,skin issues

Any Complications?

HAVE YOU HAD TREATMENTS AT ANOTHER STUDIO WITH ANOTHER THERAPIST? Answer yes or no. If yes, put how many sessions.

WILL YOU BE ABLE TO FOLLOW RECOMMENDED POST TREATMENT INSTRUCTIONS PROVIDED TO YOU BY THE STUDIO?

DID YOUR SURGEON EXPRESS IN WRITING OR VERBALLY THAT YOU SHOULD NOT FOLLOW A POST OP CARE REGIMEN INCLUSIVE OF MASSAGE AND COMPRESSION, THERMAL THERAPY OR MECHANICAL ENERGY? ANSWERING YES WILL RESULT IN DELAY OR DECLINATION OF TREATMENT BY NZURIMONADA AESTHETICS UNTIL CLEARED BY YOUR SURGEON

By SUBMITTING THIS FORM, you agree to the following:
1) I give my permission to receive post op transportation services or post op massage, body contouring treatments, skin tightening treatments, or recovery services (as outlined in separate agreement).

2) If applicable, I understand that I or the therapist may terminate the treatment session at any time. This does not apply to transportation services

3)PLEASE READ CAREFULLY AND ASK FOR CLARIFICATION IF NECESSARY. Photos of you may be taken AND may be used for social media or markteting purposes. Your identity and any identifying marks/tattoos will be concealed.

4)I am aware that our appointments are subject to late cancellation due to guidelines in place with COVID-19 regulations.

5) The medical history expressed here is truthful and thorough.

Signature

HEALTH RECORD

Terms and Conditions