BODY CONTOURING CLIENT INTAKE FORM
General Information
Name
Birthday
Address
City
State/Province
Zip/Postal Code
Phone
Format: (000) 000-0000.
Email
example@example.com
Gender
Male
Female
Occupation
Emergency Contact Name
Phone
Format: (000) 000-0000.
Would you like to be added to our email list for specials and discounts?
Yes
No
How did you hear about us?
Medical History
Do you have any chronic medical conditions that we should know about?
Yes
No
If yes, please list
Are you currently taking any medications?
Yes
No
If yes, please explain
Please list any check any health condition that is relative to you. If you don’t see a condition you have please list it below.
Do you have any cardiovascular conditions?
Do you have high blood pressure?
Do you have any thyroid problems?
Have you had cancer in the past 12 months?
Do you have photosensitivity to sun exposure?
Do you have any known kidney or liver disorders?
Do you have type 1 or type 2 diabetes?
Do you have any heart irregularities?
Do you have any medical devices implanted including, but not limited to, hearing aids, a Pacemaker, or hormonal pellets?
Other
If other, please list
What concerns would you like addressed today?
*
Do you want to lose body fat?
*
If yes, from what area
*
Do you want to tighten skin on your body?
*
Yes
No
If yes, from what area
*
Do you want to reduce cellulite?
If yes, from what area
Please list your regular exercise habits
Please describe your current dietary habits
How many ounces of water do you drink daily?
(Female clients) Are you currently pregnant or nursing?
Yes
No
When was the first day of your last menstrual cycle?
Yes
No
When was the first day of your last menstrual cycle?
By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and The Glamour Dungeon for any injury or damages incurred due to any misrepresentation of my health. Name Printed
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and The Glamour Dungron for any injury or damages incurred due to any misrepresentation of my health. Name Signature
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