Model Information
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
Marital Status
Emergency Contact Name
First Name
Last Name
Emergency Phone Number
-
Area Code
Phone Number
Medical Conditions/Questions
Are you currently taking any medications? If yes, please list them below and provide the purpose and dosage.
Do you have any allergies? If yes, please list them below:
Are you pregnant? (Women)
Yes
No
Do you drink alcohol?
Never
Occasionally
Daily
Do you drink coffee?
Never
Occasionally
Daily
Are you smoking?
Never
Occasionally
Daily
Are you taking any illicit drugs?
Never
Occasionally
Daily
Have you undergo any surgery before? If yes, please provide the surgery procedure's name, date, and reason.
Do you have a family history of any of the following? Please check the below, if none, then leave it blank.
Hypertension
Stroke
Heart Disease
Diabetes
Cancer
Anemia
Other
Medical History - Please select if you have a history of the following:
Rows
Yes
No
Asthma
Cancer
Chest pain
Chemotherapy
Diabetes
Heart Disease
Hepatitis
HIV
Kidney problems
Skin issues
Tuberculosis
Bleeding disorder
Psychiatric condition
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
Online Advertisement
Google Search
Referred by a friend
Newspaper/Magazine
Other
Patient Signature
Date Signed
-
Month
-
Day
Year
Date
Acknowledgement
I understand that this procedure cannot guarantee 100% expected results.
I understand that several treatments might be needed to achieve good results.
I allow CurvesByTre to take photographs of my before and after results as proof of the treatment.
I allow curvesbytre to use these photographs for a case studies, advertising, and marketing.
I understand that a nonrefundable model fee of $75 is required.
I confirmed that all information on this form is accurate and true the best of my knowledge.
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