Model Body Contour Intake Form

Client Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
Phone Number

Area CodePhone Number
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number

Area CodePhone Number
How did you hear about our model program? →

FacebookTwitterInstagramYouTubeTV CommercialOnline AdsPosters/BannersMagazinesNewspaperReferralOther
Body Goals and Medical Information
Which areas are you interested in contouring?
What is your main goal? → (Fat Reduction, Skin Tightening, Cellulite Smoothing, Body Sculpting)
How many times per week do you exercise?
How many cups of water do you drink daily?
Are you pregnant?

YesNo
Are you breastfeeding?

YesNo
Are you currently taking any Medications? If yes, please list them below.
Do you have any Allergies? If yes, please list them below.

Do you have any of the following?

Do you feel any pain on any part of your body? If yes, which part? Is there any Risks or Medical concerns, Pacemakers, Medical or Such that We should know about?
Acknowledgment

“I understand this is a discounted model session. Sessions may be photographed or recorded for training/marketing. Results vary per individual. This is a non-surgical, non-medical procedure.”☐ I agree and consent → Checkbox below
I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow Beauty True Body to take photographs of my before and after results as proof of the treatment.I allow Beauty True Body to use these photographs for case studies, advertising, and marketing.I was educated that hyperpigmentation might happen temporarily as a result of treatment, meaning slight bruising or feeling of soreness like a post workout after.I confirmed that all information in this form is accurate and true to the best of my knowledge.
Your Signature
Date Signed

MonthDayYear
Date
Liability Waiver
I understand that this activity might lead to personal injury therefore I release Renetta Louise Artmont, and Beauty True Body to any liabilities like personal injury and damage. I also authorize Renetta Louise Artmont, and Beauty True Body to make medical decisions for me if needed and if unable to contact an emergency contact person.
Your Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Client Information