Body Contouring

P E R S O N A L I N F O R M A T I O N

Name
Date
Date of birth:
Age
Address:
City:
State:
Zip:
Phone:
Email
Emergency contact:
Phone
How did you hear about us?
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H E A L T H H I S T O R Y

Please check any of the following conditions that applies to you:
Any other conditions:
Do you have any medication allergies?
Are you currently taking any medication (including vitamins and supplements)? List it here:
Any surgeries in the last six months?
Are you pregnant or breastfeeding?
Do you have any medical devices implanted including, but not limited to, hearing aids, a
pacemaker, or hormonal pellets?

B O D Y C O N T O U R I N G C O N S U L T A T I O N F O R M - C O N T ’ D

A D D I T I O N A L I N F O R M A T I O N

1) What concerns would you like to address today?
2) What skin problems do you think you have?
3) Do you want to lose body fat?
4) Do you want to tighten skin on your body?
5) Do you want to reduce cellulite?
5) Do you want to reduce cellulite?
7) Please describe your current dietary habits:
8) How many ounces of water do you drink daily?
Any other information you'd like to provide:

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

PAT IENT NAME (PR INTED )
PAT IENT S IGNATURE
DATE
MED ICAL PROV IDER
B E YOND BEAUTY MEDICAL AESTHETICs
WWW.BEYONDBEAUTYACADEMY.ORG