LYMPHATIC DRAINAGE & BODY SCULPTING

LYMPHATIC DRAINAGE & BODY SCULPTING

CONSULTATION FORM
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Date
Phone Number*

Area CodePhone Number
E-mail*
example@example.com
Website / Online SearchInstagramFacebookTikTokReferralOther
If someone recommended me, you’re welcome to share their name
If Other, please let me know
Medical & Health Screening
YesNo
YesNo
Heart conditionCancer / Systemic diseaseBlood clots / DVTKidney problemsDiabetesHigh or low blood pressureVaricose veins (severe)Lymphatic disordersAutoimmune conditionsRecent surgery (within 6 months)None of the aboveOther
If you have selected any of the above, please provide further details
Contraindications
Active infections / fever / illnessSkin infections or open woundsBruising or inflammation in treatment areasRecent fillers or injectables (within 2 weeks)Active acne or skin conditions in treatment areasHerniaPacemaker or implanted medical deviceNone of the aboveOther
If you have selected any of the above, please provide further details
Lifestyle & Aftercare Awareness
YesNo
YesNo
YesNo
Treatment Goals
FaceStomachWaist / SidesBackArmsGlutesThighsLower LegsOther
What are your main goals? (examples: debloating, reduce water retention, improving circulation, holiday reset, feeling lighter, overall/general wellness)*
Important Information
I understand that body sculpting and lymphatic drainage treatments are non-medical, and results vary per individualI understand that results are not guaranteed and depend on lifestyle, hydration, consistency and aftercareI confirm that all information provided is accurate and truthful to the best of my knowledgeI understand that treatment may be refused if contraindications are presentI understand that this treatment involves hands-on massage techniques and I give my consent to proceedI understand that I may ask to pause, adjust pressure, or stop the treatment at any time
Yes (face may be shown)Yes (face not shown)NoOther
Date

DayMonthYear
Date
Your personal information will be collected and stored securely for the purpose of providing safe and appropriate body sculpting and lymphatic drainage treatments. Your details will remain confidential and will not be shared with third parties unless required by law.

By signing this form, you confirm that the information provided is accurate and you consent to FG Sculpt storing and processing your data for treatment purposes.
Signature*

Powered by Jotform SignClear
Should be Empty:

LYMPHATIC DRAINAGE & BODY SCULPTING

Medical & Health Screening

Contraindications

Lifestyle & Aftercare Awareness

Treatment Goals

Important Information