Body Contouring Consultation Form

Helps an aesthetic practice collect a patient's medical history and goals during an initial body contouring consultation.

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 is your main goal?

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

I confirm the information above is correct

I confirm

Your Signature

Sign here

I authorize the clinic to proceed with the consultation and proposed treatment

I authorize

Your Signature

Sign here

Date Signed

Printed Name

Your Signature

Sign here

Date Signed

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