Client Medical Screen and Pre-Booking Form
First Day of Treatment (preferred appointment date). For appointment time choose from : 11am, 12pm, 1:30pm, or 3:00pm. Current availability is on Sundays and Mondays. SAME DAY booking is not available
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Client name (full legal name)
First Name
Middle Name ( if applicable)
Last Name
Date of Birth
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Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sex
Female
Male
Other
Listed are the medical contraindications for body contouring treatments. Please select conditions that apply currently or are historically true within the last 3 years. Your body contouring specialist will review your selections to ensure treatments to you will pose no medical harm.
Rows
Yes
Epileptic
Pregnant or trying to conceive
Metal or plastic inplant( including hearing aids)
Metal/copper IUD
Uncontrolled Diabetic
Slow healing or open wounds
Uncontrolled Anxiety/depression
Stroke/heart attack
Pacemaker
Thrombosis
Chronic kidney/liver disease
Thyroid disease
Hemophilia
Infectious disease
Autoimmune disease
Pulmonary embolism
Fibromyalgia
Cardiac/vascular conditions
Muscle/nerve condition
Cancer
High cholesterol
Arythmia
High blood pressure
HIV/AIDS
Keloids
Kidney/liver failure
Lupus
Allergy to zinc or nickel
Please fully explain any "yes" answers above.
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Which body area would you like treatment? (Select all that apply)
Abdomen
Back/"love handles"/bra roll
Legs
Arms
Butt enhancement
cellulite
Submit
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