Body Contouring Consultation Form

BODY CONTOURING

CONSULTATION FORM
Name*
Date

MonthDayYear
Date
Address
Phone #
Format: (000) 000-0000.
Email
example@example.com
Birth date

MonthDayYear
Date
Emergency Contact
Emergency Phone #
Format: (000) 000-0000.
How did you hear about us?
YesNo
If so, Please list :
YesNo
If so, Please list :
YesNo
Explain
YesNo
Explain
YesNo
List all current Medications including Vitamins
YesNo
YesNo
YesNo
YesNo
YesNo
Please give us your current Weight
Height
EpilepsyInfectionsTumorsSkin DiseasesNormal / Skin SensationThrombosis / PhlebitisAutoimmune DiseasesNeck / Back Problems
YesNo
YesNo
YesNo
YesNo
YesNo
Typical Daily Foods and Drink Intake ?
Water : How many Glasses
Coffee : How many cups
Alcohol : How much
Fast Food : type
Soda or Carbonation : Type
How Often Number/ , Tobacco Use / Recretional Drugs (narcotics) / Stress Level : Moderate Average Demanding
I consent to allow the staff members to consult with & evaluate me in order to determine if I am a good candidate for the Non-surgical Body Contouring Program. I understand that photographs and measurements will be taken and kept in my file.I agree that these forms have been completed truthfully and to the best of my knowledge/abilities.
Client Name

First NameLast Name
Client Signature

Clear
Should be Empty:

BODY CONTOURING