Body Sculpting Client Intake Form

Body Sculpting Client Intake Form
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
How did you hear about us?

FacebookTwitterInstagramYouTubeTV CommercialOnline AdsPosters/BannersMagazinesNewspaperReferralOther
Lifestyle
Height
Weight
When was the first day of your last menstrual cycle?
Are you pregnant or nursing?

YesNo
Do you exercise regularly?

YesNo
If you answered yes to the question above, how often?
Do you follow a specific diet?

YesNo
If you answered yes to the question above, which diet?
Do you consume alcohol?

YesNo
If you answered yes to the question above, how often?
Do you smoke?

YesNo
If you answered yes to the question above, how often?
Do you drink water daily?

YesNo
If you answered yes to the question above, how much?
What are your body concerns?
What are your body and/or health goals?
Medical History

Please answer completely and to the best of your ability.

Do you have any of the following?

	Yes	No	Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
Surgery
Transplants/Pacemakers
Active Infections

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 feel any pain on any part of your body? If yes, which part?
Acknowledgment
Please read thoroughly and check all that app.

I voluntarily elect to undergo this treatment, having had the nature and purpose of this treatment, along with the risks and hazards involved fully explained to me, by Hidden Figures Body Sculpting Studio.I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve optimal results.I allow HF Body Studio to take photographs of my before and after results as proof of the treatment.I allow HF Body Studio to use these photographs for case studies, advertising, and marketing purposes.I understand that specific treatments may require a virtual consultation prior to booking.I confirm that all the information provided regarding my Medical History is accurate to the best of my knowledge.I agree to inform my Technician if I experience any discomfort during the session, so they may adjust accordingly.
Your Signature

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Date Signed

MonthDayYear
Date
Liability Waiver
I confirm that I am at least 18 years of age and by signing this consent form, I agree to waive all liability towards my Technician and "Hidden Figures Body Sculting Studio" for any injury or damages incurred due to my failure to disclose any existing or past health conditions.
Your Signature

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Date
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Body Sculpting Client Intake Form

Patient Information

Lifestyle

Medical History

Acknowledgment

Liability Waiver