Body Contouring Client Intake Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
-
Area Code
Phone Number
How did you hear about us?
Facebook
Instagram
Referral
Other
Medical Condition
What part of your body do you want to lose fat or grow (butt enhancement)?
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you having regular exercise?
Yes
No
Are you currently taking any medications? If yes, please list them below.
Do you have any allergies? If yes, please list them below.
Do you feel any pain on any part of your body? If yes, which part?
Do you have any of the following?
Rows
Yes
No
Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid glad problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Undergoing hormonal therapy
HIV
Acknowledgment
I understand that this procedure cannot guarantee 100% expected results.
I understand that several treatments might be needed to achieve good results.
I allow Enhanced with Jazz to take photographs of my before and after results as proof of the treatment. (Not required)
I allow Enhanced with Jazz to use these photographs for case studies, advertising, and marketing. (Not required)
I was educated that hyperpigmentation (slight redness) might happen temporarily as a result of treatment.
I confirmed that all information in this form is accurate and true to the best of my knowledge.
Your Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
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