Name

Age

Are you pregnant or nursing?
YesNo

Have you had any major minor or cosmetic surgeries in the past 6 months?*
YesNo

Do you have any metal implants in your body?*
YesNo

Do you have any health problems including but not limited to – heart problems high blood
pressure migraines, etc.?
YesNo

I understand that photos and or videos will be taken for results purposes.
YesNo

I agree to let my photos be used for business and promotional purposes via social media and or other outlets.
YesNo

I understand that for all Body Contouring Treatments:

I can't drink coffee or alcohol within 3 hours of the appointment.
YesNo

I shouldn't consume a heavy meal within 2 hours of the appointment.
YesNo

I should drink at least 32 oz. of water.
YesNo

I understand that that for Needleless Fillers, Enhancements, and Fat Dissolvers:

I can't drink alcohol or take pain killers within 24 hours of the appointment (only arnica).
YesNo

I should drink at least 32 oz. of water.
YesNo