Lipocel body contouring schedule.

Lipocel body contouring schedule.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which part of the body will undergo the HIFU treatment?

AbdomenWaistAbdomen (lower)ArmsThighsBack (lower)Back (upper)Hips
Treatment areas*
prevnext( X )
Full Abdomen
Above and below Navel

$450.00



Lower Abdomen
Below navel only

$300.00



Outer Thigh
$250.00



Inner Thigh
$250.00



Flanks
(Love Handles)

$350.00



Knees
$200.00



Upper Back
Bra Fat

$350.00



Arm/arm
Upper arm

$350.00



Total

$0.00
Do you have any allergies?*

YesNo
What type of allergies do you have?*
Are you currently taking any medications?*

YesNo
If yes, what are the medications you're currently having?*
Are you pregnant or breastfeeding?*

YesNo
Do you have any cardiovascular disease?*

YesNo
Do you have a high blood pressure or hypertension?*

YesNo
Do you suffer from epilepsy?*

YesNo
Do you have any kind of cancer?*

YesNo
Did you undergo any surgery in the abdomen before?*

YesNo
Did you undergo any transplant?*

YesNo
Do you have any current infection?*

YesNo
Do you have any communicable disease?*

YesNo
Do you have Diabetes*

YesNo
Do you have medical device in your body*

YesNo
My signature below attests that the information above is correct.

Please note that a consent form will be signed before your procedure. We look forward to seeing you soon.
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Date Signed

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Date
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