RF and CAVITATION CLIENT INTAKE FORM

RF and CAVITATION CLIENT INTAKE FORM

Touch of Essence
General Information
Full Name
Birthday
Address
City
State/Province
Zip/Postal Code
Phone
Gender

FemaleMaleUnspecifed
Emergency Contact Name
Phone
Email*
example@example.com
How would you like to receive your updates, appointment confirmations, specials and discounts email notification?

DailyWeekly
Are you a referral?

YesNo
Enter Referrals Name?
For 10% Off Session
Medical History
Do you have any chronic medical conditions that we should know about?

YesNo
If yes, please list:
Are you currently taking any medications?

YesNo
If yes, please list:
If yes, please explain:

YesNo
If yes, please explain:
Have you had any plastic surgery?

YesNo
If yes, please explain:
Do you have type 1 or type 2 diabetes?

YesNo
Do you have any known kidney or liver disorders?

YesNo
If yes, are you currently on chemotherapy?

YesNo
Have you had cancer in the past 12 months?

YesNo
Do you have any thyroid problems?

YesNo
Do you have high blood pressure?

YesNo
Do you have any cardiovascular conditions?

YesNo
Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?

YesNo
If yes, please list:
Measurements
Weight
Height
Waist
Hip
Right Thigh
Left Thigh
Right Bicep
Left Bicep
What concerns would you like addressed today?
Do you want to lose body fat?

YesNo
If yes, from what area:
Do you want to tighten skin on your body

YesNo
If yes, from what area:
Do you want to reduce cellulite?

YesNo
If yes, from what area:
Please list your regular exercise habits:
Please describe your current dietary habits:
How many ounces of water do you drink daily?
(Female clients) Are you currently pregnant or nursing?

YesNo
When was the first day of your last menstrual cycle?
By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the spa for any injury or damages incurred due to any misrepresentation of my health.
Name Printed
Signature
Date
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the spa for any injury or damages incurred due to any misrepresentation of my health.
Name Printed
Signature
Date
Should be Empty:

RF and CAVITATION CLIENT INTAKE FORM

General Information

Medical History

Measurements