Body Contouring Client Intake Form

Body Contouring 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
Medical Condition
What specific areas would you like to target for improvement?
Do you have a diet plan? If yes, please explain below:
Have you received any body contouring or skin-tightening treatments before?

YesNo
Do you have any metal implants or body piercings in the areas to be treated?

YesNo
Are you pregnant?

YesNo
Are you breastfeeding?

YesNo
Do you regularly exercise?

YesNo
Are you currently taking any medications? If yes, please list them below.
Do you have any allergies or sensitivities, especially to oils, lotions, or any treatment materials? If yes, please list them below.

Do you have any of the following?

	Yes	No	Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid gland problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
High Blood Pressure

Do you feel any pain on any part of your body? If yes, which part?
Acknowledgment
I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow Luxsthetics Recovery to take photographs of my before and after results as proof of the treatment.I allow Luxsthetics Recovery to use these photographs for case studies, advertising, and marketing.I was educated that hyperpigmentation might happen temporarily as a result of treatment.I confirmed that all information in this form is accurate and true to the best of my knowledge.I understand and acknowledge that there are risks involved with the treatment I will bereceiving including, but not limited to:• Redness• Swelling• Irritation• Skin reaction• Increased heart rate
Your Signature

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Date Signed

MonthDayYear
Date
Liability Waiver
I have read and fully understand this agreement and all information detailed above. I
understand the procedure and accept the risks. I agree I will assume the risk and full
responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the technician responsible for any of m yconditions that were present, but not disclosed at the time of this procedure, which may beaffected by the treatment performed today.

I understand that this activity might lead to personal injury therefore I release Luxsthetics Recovery to any liabilities like personal injury and damage. I also authorize Luxsthetics Recovery to make medical decisions for me if needed and if unable to contact an emergency contact person.
Your Signature

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Date Signed

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Date
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Body Contouring Client Intake Form

Patient Information

Medical Condition

Acknowledgment

Liability Waiver