Body Contouring Client Intake Form

Gathers a prospective patient's health background and aesthetic goals ahead of a body contouring appointment.

Use this template

Full Name

Nombre

Apellido

Age

Date of Birth

Gender

Male Female Other

Email

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Emergency Contact Person

Nombre

Apellido

Emergency Contact Phone Number

How did you hear about us?

What part of your body would you like to reduce fat from?

Do you follow a diet plan? If so, please explain below

Are you pregnant?

Yes No

Are you breastfeeding?

Yes No

Do you exercise regularly?

Yes No

Are you currently taking any medications? If so, please list them below

Do you have any allergies? If so, please list them below

Do you feel pain in any part of your body? If so, where?

I understand that this procedure cannot guarantee 100% of the expected results

I understand and agree

Your Signature

Sign here

Date Signed

Printed Name

Your Signature

Sign here

Date Signed

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