Client Intake Form

Client Intake Form
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
To best serve you, Glow Body Sculpt needs a brief overview of your health. Thank you for answering our intake questions!
Do you have any of the following health issues?

Allergies Uncontrolled Blood Pressure Thyroid Problems Congestive Heart Failure Epilepsy Pregnancy Multiple Sclerosis Any recent joint injuries Recent wounds from surgery A Pacemaker Metal rod or any surgical implants Issues with blood clotting Other conditions
If you answered yes to any of the above boxes, please add any additional info here. Thank you!
Are you over 18 years of age and under 65 years of age?
Should be Empty:

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To best serve you, Glow Body Sculpt needs a brief overview of your health. Thank you for answering our intake questions!