Shape and Sculpt Consultation

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Emergency Contact *

First Name

Last Name

Phone *

(###)

###

####

Have you consumed at least three glasses of water today prior to treatment? *

Yes

No, but I will have some now.

Check if you have or had any of the following, if yes briefly explain: *

Pregnant

Breast Feeding

HIV /AIDS

Bleeding Disorders

High Cholesterol

Liver Disorders

Skin Disorders

Respiratory Disorders

Neurological Disorders

Cardiac Disorders

Lymphatic Disorders

Psychological Diagnosis

Diabetes

Pace Maker or Devices in Body

Metals in Body

Seizures

Cancer

Acute Illness (cold/flu/diarrhea, etc.)

None

Skin Condition *

Dry

Oily

Normal

Acne Prone

Is your skin fragile or sensitive? *

No

Yes

Do you have problems healing from injury to skin? *

No

Yes

Have you ever had a cold sore? *

No

Yes

Are you primarily inside or outside? *

Inside

Outside

Do you currently use sun block regularly? *

No

Yes