Body Contouring Client Intake Form

Body Contouring Client Intake Form
Patient Information
Name
First NameLast Name
Age
Date of Birth
MonthDayYear
Date
MaleFemale
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.
FacebookTwitterInstagramYouTubeTV CommercialOnline AdsPosters/BannersMagazinesNewspaperReferralOther
Medical Condition
What part of your body do you want to lose fat?
Do you have a diet plan? If yes, please explain below:
YesNo
YesNo
YesNo
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
I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow ABC Beauty Center to take photographs of my before and after results as proof of the treatment.I allow ABC Beauty Center to use these photographs for case studies, advertising, and marketing.I was educated that hyperpigmentation might happen temporarily as a result of treatment.I confirmed that all information in this form is accurate and true to the best of my knowledge.
Your Signature
Clear
Date Signed
MonthDayYear
Date
Liability Waiver
I understand that this activity might lead to personal injury therefore I release ABC Beauty Center to any liabilities like personal injury and damage. I also authorize ABC Beauty Center to make medical decisions for me if needed and if unable to contact an emergency contact person.
Your Signature
Clear
Date Signed
MonthDayYear
Date
Should be Empty:

Patient Information