BODY INTAKE FORM Name * First Name Last Name Date of Birth * MM DD YYYY Phone * (###) ### #### Email * Emergency Contact Name * First Name Last Name Emergency Contact Phone Number * (###) ### #### Do you have any of the following medical conditions? * Heart Disease Diabetes Hypertension Liver or kidney disorders Cancer Blood clots or circulatory issues Skin disorders or infections Metal implants or pacemaker None of the above Are you currently pregnant or breastfeeding? * Yes No Do you have any recent injuries, surgeries, or conditions that may affect treatment? * Are you currently taking any medications or supplements? * Have you previously had body sculpting or similar procedures? * Consent & Waiver * I understand that body sculpting is a non-invasive cosmetic treatment and is not intended to diagnose, treat, cure, or prevent any medical condition. I acknowledge that results vary by individual, and there are no guarantees regarding outcomes. I confirm that all information provided is accurate and complete to the best of my knowledge. I consent to photographs or measurements, if required, to monitor my progress. I understand that all treatments are strictly for personal use only and may not be transferred. Thank you!
