Body Contouring Client Intake Form

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
Please enter a valid 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
Please enter a valid phone number.
How did you hear about us?

Facebook Twitter Instagram YouTube TV Commercial Online Ads Posters/Banners Magazines Newspaper Referral Other
Medical Condition
What part of your body do you want to lose fat?
Do you have a diet plan? If yes, please explain below:
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 have any of the following?

Do you feel any pain on any part of your body? If yes, which part?
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 Kandiedbodies to take photographs of my before and after results as proof of the treatment. I allow Kandiedbodies to use these photographs for case studies, advertising, and marketing. I confirmed that all information in this form is accurate and true to the best of my knowledge.
Liability Waiver
I understand that this activity might lead to personal injury therefore I release Kandiedbodies to any liabilities like personal injury and damage. I also authorize Kandiedbodies to make medical decisions for me if needed and if unable to contact an emergency contact person.
Your Signature

Clear
Date Signed

Month Day Year
Date
Should be Empty:

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Patient Information