Intake and Evaluation Form

Name*

First NameLast Name
Age *
Date of birth *
sex*

FemaleMale
gender pronoun*

she/herhe/himtheyotherOther
Address*

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?*

YESNO
If so what procedures? Please be thorough and lIst all areas*
WHAT SERVICES ARE YOU INTERESTED IN?*

POST OP SERVICESBODY CONTOURING/NON SURGICAL FAT LOSSFACIAL CONTOURINGSKIN TIGHTENINGPERSONAL CARE SERVICES (including transportation and/or post op companion services)PRE-OP CONSULTCOMPRESSION CONSULTATIONPOST OP CONSULTATION (reside outside of New York area)OTHEROther
GOALS*

LOOK BETTER NAKEDLOOK BETTER IN CLOTHESFIND QUALITY POST OP CAREGET INFORMATION ABOUT SURGICAL AND NONSURGICAL OPTIONSDETOXWEIGHT LOSSGET READY FOR A SPECIAL EVENTOTHEROther
Favorite music artist/Genre
How did you hear about us?*
Whats your IG or FB? Only lIst one or the other
HEALTH RECORD
Please check all that currently apply.*

Eye conditions - Blepharitis / Eye infectionsPregnant or PostpartumMenopauseAsthmaCancerDiabetesHead achesLow Blood PressureDepressionAnxietyBruise EasilyFibromyalgia Other Auto Immune DisordersUsed Retin -A within the past month?Hormone TreatmentNone of these applySomething not listed (please write in)High blood pressureOther
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? *

ExcellentGoodFairPoor
What was/is the date of your Surgery?*
Surgeon's name and number*

Surgeon Name

Phone Number
Did you receive Post op instructions*

YesNoN/A
Drains/wounds,skin issues*

DrainsOpen lipo holesClosed lipo holesTummy tuck scar (healing)Tummy tuck scar (new)Wound dehiscence/separationN/ASomething else/ I don’t know what it’s called
Any Complications?*

noyes and I was hospitalized for itnot hospitalized but have to follow up for complicationsI think I have complications but I'm unsure what to do
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?*

YESNOI DO MY OWN THING AND MAY OR MAY NOT FOLLOW SUGGESTIONS
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*

YesNo
Terms and Conditions
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*

Clear
Should be Empty:

HEALTH RECORD

Terms and Conditions