VVSpa - Body Contouring Intake Form
Patient Information
Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Male
Female
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
How did you hear about us?
Facebook
Twitter
Instagram
YouTube
TV Commercial
Online Ads
Posters/Banners
Magazines
Newspaper
Referral
Other
Medical Condition
What body areas would you like us to focus on?
What are your weight loss expectations with us?
Are you pregnant?
Yes
No
Are you breastfeeding?
Yes
No
Are you having regular exercise?
Yes
No
Are you currently taking any medications? If yes, please list them below.
Type a question
Rows
Before
Goal (By End)
Waist Measurement
Weight
Do you have any allergies? If yes, please list them below.
Do you have any of the following?
Rows
Yes
No
Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid glad problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
Do you feel any pain on any part of your body? If yes, which part?
Acknowledgment
Check The Following
I understand that this procedure cannot guarantee 100% expected results.
I understand that several treatments might be needed to achieve good results.
I allow VV Massage to take photographs of my before and after results as proof of the treatment.
I allow VV Massage to use these photographs for case studies, advertising, and marketing.
I confirmed that all information in this form is accurate and true to the best of my knowledge.
Your Signature
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
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