Salon & Spa Appointment Booking

1

Full Name* This field is required.

First Name

Last Name

2

Email Address* This field is required.

example@example.com

3

Phone Number* This field is required.

Please enter a valid phone number.

4

Have you had Body Sculpting before?

Yes

No

5

If you have answered yes; what have you had done?

6

What is your age?

9

What is your main goal for the treatment?

Fat Reduction

Skin Tightening

Cellulite Reduction

Contouring your body

Lifting & Toning

10

Additional Requests or Notes

11

Using your hand, gently press and feel the area you’re concerned about. Does the fat in this area feel soft and jiggly, or more firm and structured?Please advise to the best of your knowledge. This helps determine which treatment might be best for you. There is no incorrect answer.

Soft & Jiggly

Firm & Structured

Both

12

What is your current weight?

13

Do you currently follow a regular diet or exercise routine? If so, please describe what a typical day of eating and physical activity looks like for you.

14

Do you have any past or current medical conditions that require ongoing treatment, monitoring, or regular medication? If applicable, please specify any diagnosed conditions such as PCOS, endometriosis, diabetes, cancer, thyroid disorders, cardiovascular conditions, or any other relevant health concerns.This helps me better understand your treatment options, please answer this as honest as you can.

15

Are you currently breastfeeding or pregnant?

YESNO

16

Have you had surgery on the area you are wanting to treat in the last 12 months?

YESNO

17

Are you currently taking Accutane/Roaccutane, or have you taken it in the past? If yes, please specify the duration of use and the date you discontinued the medication

18

Liability Acknowledgement: By signing you are confirming your acknowledgement.