Body Assessment Form
For Body Sculpting & Lipodissolve Treatments
Date
*
-
Month
-
Day
Year
Date Picker Icon
Name
*
First Name
Last Name
E-mail
*
Your Body
What are your areas of concern?
*
Stomach
Arms
Legs
Back (bra area)
Flank
Under buttocks
Love Handles
Other
Please feel free to go into more detail
Have you ever had a body sculpting prior?
*
Yes
No
Your Assessment
Draw On Image
Area of concern
Weight
BMI Calculator
Chest measurement
Waist measurement
Hip measurement
Arm measurements
Left
Right
Leg measurements
Left
Right
Area of concern measurement
Client Signature
*
Therapist Signature
*
Submit
Should be Empty: