Body Sculpting Client Intake Form

Body Sculpting Client Intake Form
Patient Information
Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Gender
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.Format: (000) 000-0000.
How did you hear about us?

Other
Lifestyle
Height
Weight
When was the first day of your last menstrual cycle?
Are you pregnant or nursing?
Do you exercise regularly?
If you answered yes to the question above, how often?
Do you follow a specific diet?
If you answered yes to the question above, which diet?
Do you consume alcohol?
If you answered yes to the question above, how often?
Do you smoke?
If you answered yes to the question above, how often?
Do you drink water daily?
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?

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.
Your Signature
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
Date Signed

MonthDayYear
Date
Should be Empty:

Patient Information