Forms Photo Consent Release PHOTO CONSENT & RELEASE FORM DOWNLOAD FORM Appointment & Cancellation Policy Appointment & Cancellation Policy Download Form Hipaa Confidentiality Agreement Hipaa Confidentiality Agreement Download Form CLIENT INTAKE FORM General Information * First Name Last Name Date of Birth * Phone Number * Email * Instagram Handle Sex * Male Female Other Emergency Contact Name * Emergency Contact Phone Number * Medical History Have you had any plastic surgery? * No Yes Chronic conditions? * No Yes Current medications? * No Yes Allergies? * No Yes Type 1 or 2 Diabetes? * No Yes Kidney/Liver Disorders? * No Yes Cancer diagnosis or chemotherapy in last 12 months? * No Yes Thyroid issues? * No Yes High Blood Pressure? * No Yes Cardiovascular conditions? * No Yes Metal in body? * No Yes Medical devices (e.g. pacemaker, pellets)? * No Yes Infectious diseases? * No Yes Treatment Goals & Preferences Lose body fat? * No Yes Tighten skin? * No Yes Reduce cellulite? * No Yes Regular exercise habits: * Describe dietary habits: * Water intake (oz/day): * Female Clients Only Are you currently pregnant or nursing? No Yes First day of your last menstrual cycle: Consent & Acknowledgment Date MM DD YYYY * I have completed this form truthfully and to the best of my knowledge. I agree to inform the technician of any changes in my health status or medications. I understand that my technician will adjust treatment accordingly and that I may stop treatment at any time. I waive all liability toward the technician and spa for any injury or damages incurred due to undisclosed health information. Thank you! For your submission any questions please contact us.
