Client intake form

Beautiful You Body Sculpting
4204 Cedar Ave S
Minneapolis MN 55407
651-760-8351
Ultrasonic Fat Cavitation & RadioFrequency
Intake form

You can either print and fill out this intake form before your appoint or you may fill it out before your treatment, you will have to fill it out.

Client Information

Name:___________________________________

Telephone:________________________________

Email: ____________________________________

Address: ________________________________

City: ___________________________________

State: __________________________________

Zip Code: _________________________________

Date of Birth: _______________________________

In case of emergency: _____________________

Phone: ___________________________________

Physician: _________________________________

General Medical Information
Please check the appropriate boxes next to the questions regarding your health
QUESTIONS
Check either YES or NO
YES
NO
Do you suffer from epilepsy or seizure?

Are you pregnant or nursing?

Do you have diabetes?

Do you have any kind of tumor or cancer?

Do you have any cardiac or vascular disease or a condition?

Do you have any acute inflammation?

Do you have a wound that has not healed?

Do you have current or any history of internal bleeding?

Do you have a pacemaker or other electronic devices?

Do you have any plastic or bone cement or any large metal implant?

Have you had abdomen operations?

Do you have abnormally high or low blood pressure?

Do you have hemophilia?

Do you have melanoma?

Do you have thrombosis and/or thrombophlebitis?

Have you under gone a transplant?

Are you being treated with anticoagulants?

Do you have any keloids?

Do you have any kind of heart trouble?

Do you have any current infections?

Do you have any infectious disease or tuberculosis?

Do you have advance untreated diabetes?

Do you have communicable diseases?

Do you have any type of heart, kidney, liver disease?

Are you taking any vitamins?

Are you taking any supplements?

Are you allergic to any foods or medications?

Are you currently under a physician’s care?

If you answered Yes to the above question what for?

If you answered YES to any of these questions YOU MAY NOT be eligible for the treatment.
EXPLAIN YES ANSWERS
____________________________________________________________________________________________________________________

Few more questions to answer*
List any medication you are currently taking. ______________________________________________________________________________________________________________________________________________________________________________

Explain any current medical conditions. ____________________________________________________________________________________________________________________

Please take moment to read the following information and sign where indicated. If you have a specific medical condition or specific symptoms, Ultrasonic Fat Cavitation or Radio Frequency procedures may be contraindicated. A referral from you primary care provider may be required prior to service being provided.
I understand that the Ultrasonic Fat Cavitation or Skin Tightening Radio Frequency procedure I receive is provided for the basic purpose of non–invasive treatment used to remove fat from within the connective tissue or tighten and lift the skin through dermal heating, without surgery or injections. This If I experience any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and /or temperature may be adjusted to my comfort level. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Beautiful You Body Sculpting does not guarantee any specific result. The Ultrasound Cavitation/Radiofrequency Skin treatment includes, but is not limited to the use of high-power low-frequency ultrasound cavitation which uses 25-28KHz the pressure around the adipocyte and forces it to implode, thus breaking down adipocyte’s cell membrane. After Care: After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.
I further understand that Ultrasonic Fat Cavitation or Radio Frequency procedure should not be construed as a substitute for medical examination, diagnosis, or treatment.
I understand that Ultrasonic Fat Cavitation or Radio Frequency procedure does not diagnose, prescribe or treat any physical that nothing said in the course of the session given should be construed as such because the Ultrasonic Fat Cavitation or Radio Frequency procedure should not be performed under certain medical conditions.
I affirm that I stated all my known medical conditions and answered all the questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile. I understand that there shall be no liability on the practitioner’s part should I fail to do so.
Before, During and After Pictures: Before during and after pictures or videos may be taken to document the treatment. These pictures or videos become Beautiful You Body Sculpting sole property and may only be used for its legitimate business purposes.

Client Signature:

________________________________________

Date: ________________________________