Body Sculpting Consultation Form

Name* This field is required.

First Name

Last Name

Email* This field is required.

example@example.com

Phone Number* This field is required.

Please enter a valid phone number.

Your age* This field is required.

Please enter your current age

Have you had any body sculpting treatments before? * This field is required.

YESNO

If yes to the previous question, which ones?

Which areas would you like to target?* This field is required.Choose as many as you like

Full face

Full face & neck

Chin / Jawline

Neck only

Décolletage (Chest)

Axillar (Bra bulge)

Lower stomach

Upper stomach

Flank (sides of stomach)

Love handles / Hips

Lower back

Upper back

Arms

Inner thighs

Outer thighs

Back of thighs

Calves

Buttocks

Male's pecks

What are your main body / face concerns?* This field is required.

Stubborn Fat

Loose Skin

Cellulite

Wrinkles & Fine lines

Double Chin

What is your main goal for the treatment?* This field is required.

Fat reduction

Skin tightening

Lifting + Toning

Body Contouring

Other

(For the body) With your hand, please press, shake & feel your area of concern, would you consider the fat in that area to be jiggly / loose? or firm?* This field is required.There is no right or wrong answer, this is to help determine which treatment is best for you.

Jiggly / Loose

Firm

Both

What is your current weight?* This field is required.Please asnwer this in Kg.

What is your current height* This field is required.Please asnwer this in either cm or ft & inches

Do you follow a regular diet or exercise routine? what does a day of eating & exercising look like for you? (Yes/No, If yes, please describe)* This field is required.

Would you be willing to make healthy lifestyle changes to better your wellbeing and commit to hitting your goals?* This field is required.

YESNO

Do you have any medical conditions or take any medications that we should be aware of? (Yes/No, If yes, please specify)* This field is required.

Are you pregnant or breastfeeding? (Yes/No)* This field is required.

YESNO

Have you recently (In the last 12 months) had any surgery in the areas you want treated? (Yes/No, If yes, please specify).* This field is required.

Do you currently take any accutane / roaccutane medications? or have you in the past? if so please specify how long for / or when you got off the medication.* This field is required.

Do you currently use Retinol / Vitamin A cream? (yes/no) if so, are you able to pause the usage of the cream for 2 weeks leading up to each treatment? (yes/no)* This field is required.Please answer yes or no to both questions.

Can you please upload images (as clear as possible) of the areas you would like to treat? * This field is required.This will help me analyse the areas myself, to determine which treatments are best for you.

Have you done any research on body sculpting treatments? If so, which ones are you interested in?* This field is required.it's okay if you have not done any research, this is what i'm here for! But if you have, i would love to know.

How soon are you looking to start your journey?* This field is required.

ASAP

Within a month

2-3 months

Just exploring my options

Do you have any questions or concerns you’d like to discuss? Please leave below and I will answer for you.* This field is required.

Body Sculpting Consultation Form