Body Sculpting Intake Form

Thank you for your interest in having your body sculpting procedure with us. We are with you on your desire to reach your goals for a better body that helps boost your confidence and bring a better lifestyle. We have provided some information that can help you achieve your best results:

Avoid eating two hours before and after treatment
Avoid heavy meals on treatment days
Drink plenty of water to facilitate lymphatic drainage
Limit carbonated drinks, coffee, and tea during treatment period
Avoid Fasting or body will go into “starvation mode” and become more resistant to the release of stored fat
NO Alcohol Prior to treatment

Please take note that results may vary for the treatment. During the treatment, you might feel a warm discomfort. If it's not tolerable, please advise our technician.

Name

First Name Last Name

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

Date of Birth

Date

Age

Contact In Case Of Emergency

Name

First Name Last Name

Phone Number

Please enter a valid phone number.

Relationship

What concerns would you like addressed today?

Abdomen Arms Buttocks Cheeks Chin Legs Thighs Other

Non-Candidate

	Yes	No
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?

Medical History

	Yes	No
Are you pregnant or nursing?
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?
Do you have advanced untreated diabetes?
Do you have uncontrolled Hypertension?
Do you have any kind of heart condition?
Do you have hemophilia (blood clotting condition)?
Do you have a keloid scar?
Do you have any infectious disease or tuberculosis?
Do you have a pacemaker?

If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.

Reminder:

Please make sure that there are no metal instruments that are present on or in your body during the scheduled treatments. If you have any heart or liver problems, uncontrolled high blood pressure, or cancer or undergoing radiology treatments, please see your doctor first. However, if you have a pacemaker, it is unfortunate that we cannot proceed with any of the services that we offer.

CONSENT I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I allow Body By Bemilly to take photographs of my before and after results as proof of the treatment. If you do not wish to take photographs, we have the right to decline to serve you. I allow Body By Bemilly to use these photographs for case studies, advertising, and marketing.I understand that non-invasive surgery procedures do not rid the body of visceral fat. I hereby release and forever discharge Body By Bemilly, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless from Body By Bemilly for any liabilities, damages, injuries whether seen or unforeseen. I understand that any procedure under Body By Bemilly does not constitute medical treatment or cure to any illness. By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions, which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence. I confirmed that all information in this form is accurate and true to the best of my knowledge.

Signature

Clear

Date