Body Sculpt Intake Form
Please take a minute to fill in the following info
First Name
Last Name
Email
Phone Number
Birth Date
How did you hear of SBH?
Do you have any chronic medical conditions which we should know about, yes or no? If yes, please explain
Do you have any allergies to latex, medications, herbal or natural supplements, yes or no? If yes, please explain.
Do you have, or have you had, any changes in medical history recently. Ex. Gallbladder Removed, History of Gallstones, History of Liver Problems, Have you had any surgeries?yes or no? if yes to any, please explain
Do you have Hearing aids, Pacemaker or metal/medical devices implanted, yes or no? If yes, please explain
Do you have type 1 or type 2 Diabetes, yes or no? If yes, please explain
List all current Medications including Vitamins
Do you have or have you had Cancer in the last 12 months, yes or no? If yes, please explain.
Do you have a Thyroid problem, High Blood Pressure or a Cardiovascular conditions, yes or no? If yes, please explain
Are you currently pregnant or nursing, yes or no?
Please give us your current Weight and Height
Mark which applies to you:
Epilepsy
Normal Skin Sensation
Neck/Back Problems
Infections
Blood Clots
Tumors
Skin Diseases
Autoimmune Disease
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.
Date
Your Signature
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Emergency Contact: Phone # and Contact name
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