Lipo Massages of South Florida - WELCOMES YOU!
Hello, answering these questions will help us understand your desired goals, so we can then help you look beautiful and feel your best, as quickly as possible.
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Must Be at least 18 years of Age.
Gender
Male
Female
Please tell us how you want us to contact you. (select all that apply)
*
Email
Cell phone
Text
How did you find us? Google search (key word)... Instagram (key word)... or referral from a friend, doctor or health care provider. Please list their name so we can thank them.
*
What was the date of your lipo surgery? Were there any complications?
*
What is your Lipo Doctor's name and office phone number?
Are you on an antibiotic from the surgery?
*
What medications were you taking a week before the surgery?
*
Say None If None.
What is your current level of pain from the surgery? (1-10, 10 being a very high Level of pain)
*
What supplements/vitamins do you currently take?
Say None if None.
Any known allergies or sensitivities? Pollen, foods, latex, etc
Are you active or being treated for any contagious conditions? (Check all that apply)
*
HIV, AIDS
Staff Infection, MRSA
Hepatitis B
Cold, Flu
Herpes, Shingles
Tuberculosis, TB
COVID-19
COVID-19, and tests now show non-contagious
None
Nutrition Information -- Optional
Your diet affects inflammation, your pain level and how quickly you will heal. If you would like us to help you heal faster, please fill out this section.
Would you enjoy learning about "Natural Healing Techniques" that can help you heal faster?
Height
Weight
Would you like to gain weight, loose weight, or stay the same?
What do you typically eat for breakfast?
What do you eat for lunch?
What do you eat for dinner?
What kind of snacks do you eat?
How much water & other beverages do you drink throughout the week.
Do you have any cravings... sweets, coffee, chocolate, cigarettes or other?
Have you tried any diets? For how long? Any success?
Have you ever kept a food journal or diary?
Do you cook?
What percent of your food is cooked at home?
Where do you get the rest from?
Have you ever tried juicing or making smoothies?
Do you have any interest in learning about juicing or making smoothies?
Do you own any of the following?
Blender
Juicer
Vitamix, Nutribullet, Nija
Rice Cooker
Crock Pot
Instantpot
What are 1-3 things that you know you can do and should do to improve your health?
Our goal is to help you heal fast from your surgery and to look and feel your best! Is there anything else you would like us to know?
Thank You!
Press the Click Here to Send button and we will call you to answer any questions and to schedule your lipo massage appointment!
Click Here to Send
Should be Empty: