Massage & Body Contouring Intake Form
Client Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Health Data
Interested Service(s)
CBD Massage (Pain Relief)
Brazilian Lymphatic Massage
Post-Op Brazilian Lymphatic Massage
Cellulite Treatment
Cavitation Treatment (Fat Reduction)
Ultrasound Liposuction (Fat Burning)
Ultrasound Liposuction (Fat Burning with Electro muscular Stimulation)
"Liquid Lipo” Lipo Dissolver Injection
Kybella
Other
What area are you looking to get treated
Chin
Arms
Abdomen
Upper back ( Bra Area)
Flanks
Abdomen
Upper thighs
Do you have any allergies?
If yes, please specify on the field above.
Are you currently taking any medications?
If yes, please specify on the field above.
Are you pregnant or nursing?
If yes, please specify on the field above.
Have you been recently hospitalized?
If yes, please specify on the field above.
Do you have any current injuries?
If yes, please specify on the field above.
Current medical conditions like asthma, diabetes, heart problems, kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Location of painful areas
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize FMW Services to perform the treatment or necessary procedure for my child.
I authorize the use of lotion, oil, and ointments to my body.
I acknowledge that I have consulted a physician before undergoing this massage treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I release this massage spa clinic/center for any responsibility in case of an accident, illness, or injury.
I acknowledge that all information I provided in this form is true and accurate.
Signature of the Client
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: