MLD & Body Sculpting Consult Form
Date
-
Month
-
Day
Year
Date
Referred by:
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
D.O.B:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name:
Emergency Contact Number:
Would you like to be added to our email list for specials and discounts?
Yes
No
Do you have any chronic medical conditions that we should know about?
Yes
No
If answered yes, please explain:
Are you currently taking any medications, vitamins or herbs?
Yes
No
If answered yes, please explain:
Do you have any allergies?
Yes
No
If answered yes, please explain:
Do you have history of Blood Clots and or Blood Clotting Disorders?
Yes
No
If answered yes, please explain:
Have you had any medical procedures, recently or in the past?
Yes
No
If answered yes, please explain:
Do you have any medical devices implanted including, but not limited to, hearing aid?
Yes
No
If answered yes, please explain:
Please select any following that apply. Check for past and present.
Light /Sun Sensitivity
Kidney/Liver Conditions
Cancer
Thyroid Problem
High/Low Blood Pressure
Pregnant/Nursing
Implants
Diabetes
Currently Ill
Bruise Easily
Vascular/Cardiovascular Condition
COVID
HIV
Herpes
Blood Clotting Condition
Asthma
Lymph Node Removal
What exactly would you like to get out of this procedure?
Do you want to lose body fat?
Yes
No
If answered yes, please explain:
Do you want to reduce cellulite?
Yes
No
If answered yes, please explain:
How many ounces of water do you drink daily?
List your regular exercise habits?
I have, to the best of my knowledge given accurate answers to questions on my medical history
Yes
No
If answered yes, please explain:
Signature
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