Firming Treatment - Intake Form
In Conjunction with Body Contouring
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Date Of Birth
-
Month
-
Day
Year
Date
Sex
Phone Number
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Email
example@example.com
Medical History
Are you currently under any medical treatment?
Yes
No
If Yes, Please provide a brief description:
Do You Have Any Allergies To Latex, Medications, Herbal or Natural Supplements?
Yes
No
If So Please List Them:
Do You Have or Have You Had, Any Changes In Medical History Recently?
Yes
No
If So Please List Them:
Please check which applies to you:
Pregnancy
Epilepsy
Allergies
Insomnia
Varicose veins
Back Injuries
Claustrophobia
Hypertension
Heart Problems
Osteoporisis
Diabetes
Breathing Problems
Pace Maker
Cancer
HIV / AIDS
Skin Lesions
High Blood Pressure
Low Blood Pressure
Other
Do you have any allergies to Iodine (seafood, etc..)
Yes
No
Explain
Have you ever had a reaction to any body treatment?
Yes
No
Do you have any medical implants?
Yes
No
Do you have any allergies?
Yes
No
If yes, please explain
Are you taking medications?
Yes
No
If yes, please explain
RELEASE OF LIABILITY
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I agree to Bella Day Spa giving face/body treatment(s) under the terms and conditions described above. I also agree that these forms have been completed truthfully and to the best of my knowledge/abilities.
I Agree
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: