Body Contouring Client Intake Form

Body Contouring 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
Medical Condition
What part of your body do you want to lose fat?
Do you have a diet plan? If yes, please explain below:
Are you pregnant?
Are you breastfeeding?
Are you having regular exercise?
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 have any of the following?

Do you feel any pain on any part of your body? If yes, which part?
Acknowledgment
Your Signature
Date Signed

MonthDayYear
Date
Liability Waiver
I understand that this activity might lead to personal injury therefore I release Bodied By You Inc to any liabilities like personal injury and damage. I also authorize Bodied By You Inc to make medical decisions for me if needed and if unable to contact an emergency contact person.
Your Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Patient Information