Lipo Laser Intake Form

Lipo Laser Intake Form
Date

MonthDayYear
Date
Name
DOB
AGE
Address
Phone
Occupation
Email
example@example.com
LipoLaser is a noninvasive procedure that may help to liquify fat cells and stimulate the production of collagen which results in firmer, tighter and smoother skin. While laser liposuction is safe with some medical conditions, some of the following are known contraindications to laser liposuction. Please check any that apply and consult with your practitioner if you are unsure or have questions. Failure to truthfully identify any contraindicated medical conditions you knowingly have can result in serious adverse effects including but not limited to injury or death.
Medical Background: Check all that apply (Past & Present)

PregnancyEpilepsyBleeding DisorderHypertensionCancerCariac/VascularRecent Surgical IncisionFeverHerniasUnhealed WoundsSunburnCaradiopathyTransdermal Drug Delivery SystemTransplantThyroid Disorders/DiseaseHives, Herpes, ShinglesAnticoagulants (Blood Thinners)Organ FailureInfectionDislocationsPacemaker/Other Electronic Device ImplantInsulin MonitorHeart/Kidney/ Liver DiseasePlastic/Bone Cement/Metal Implants
By signing below, you agree to the following:

I have completed this form to the best of my ability and knowledge and agree to inform my practitioner of any changes to the information listed on all pages of this intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my practitioner of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my practitioner and the company in which I am voluntarily seeking services from for any injury or damages incurred due to any misrepresentation of my health history.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: