Fat Cavitation Client Intake Form

Prepare every cavitation session with a complete client record: contact details, a thorough medical history, baseline body measurements, and aesthetic goals. With consent signatures included, your clinic works fully covered.

Use this template

Full Name

Birthday

Address

City

State/Province

Zip/Postal Code

Phone

Gender

Female Male Prefer not to say

Emergency Contact Name

Phone

How would you like to receive updates, appointment confirmations, specials, and discounts?

Email Text message Phone call No notifications

Are you a referral?

Yes No Not sure

Enter the referral's name

Do you have any chronic medical conditions that we should know about?

Yes No Not sure

If yes, please list:

Are you currently taking any medications?

Yes No Occasionally

If yes, please list:

Do you have any allergies?

Yes No Not sure

If yes, please explain:

Have you had any plastic surgery?

Yes No Prefer not to say

If yes, please explain:

Do you have type 1 or type 2 diabetes?

Type 1 Type 2 No

Do you have any known kidney or liver disorders?

Yes No Not sure

If yes, are you currently on chemotherapy?

Yes No Not applicable

Have you had cancer in the past 12 months?

Yes No Prefer not to say

Do you have any thyroid problems?

Yes No Not sure

Do you have high blood pressure?

Yes No Not sure

Do you have any cardiovascular conditions?

Yes No Not sure

Do you have any implanted medical devices, including but not limited to hearing aids, a pacemaker, or hormonal pellets?

Yes No Not sure

If yes, please list:

Weight

Height

Waist

Hip

Right Thigh

Left Thigh

Right Bicep

Left Bicep

What concerns would you like addressed today?

Do you want to lose body fat?

Yes No Maybe

If yes, from what area:

Do you want to tighten skin on your body?

Yes No Maybe

If yes, from what area:

Do you want to reduce cellulite?

Yes No Maybe

If yes, from what area:

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?

(Female clients) Are you currently pregnant or nursing?

Pregnant Nursing No Not applicable

When was the first day of your last menstrual cycle?

Client informed consent

I have read and understand the information above.

Name Printed

Signature

Sign here

Date

For practitioner use only

Name Printed

Signature

Sign here

Date

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