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Client Intake Form
Client Intake Form
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2018-02-20T15:59:56+00:00
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Name
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Last
Date of Birth
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Address
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First Name
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Email address
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Phone
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Emergency Contact
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Emergency Contact Phone
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How did you hear about us?
Medical History
I am over 18 years old and have proof of identification.
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Yes
No
I have cardiovascular disease or disorder (ex. pacemaker or defibrillator)
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Yes
No
I am pregnant or breastfeeding
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Yes
No
I have skin lesions
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Yes
No
I have retinal detachment
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No
I have thyroid gland dysfunctions
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No
I have liver disease
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Yes
No
I have photosensitivity to sun exposure
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Yes
No
I have kidney disease
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Yes
No
I have gastrointestinal issues (ex. IBS, Crones)
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Yes
No
I do not have cancer or have been in remission within one year
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Yes
No
I am taking medications which cause photo- sensitivity
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Yes
No
I have a compromised immune system
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Yes
No
I have regular bowel movements
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Yes
No
I have disease or disorder stimulated by light (ex. Epilepsy)
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Yes
No
Are you cleared to exercise?
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Yes
No
Do you have any aches, pains or injuries we should be aware of before your workout? If yes, please list here:
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Photography
I consent to taking before and after photographs and authorize their ANONYMOUS use for the purpose of medical audit, education, and/or promotion.
Acknowledgement
I understand that there are no guarantees to the results of this treatment. I understand to achieve maximum results, I may require several treatments.
To achieve optimum results, I understand that an appropriate diet and regular exercise will assist to sustain and create a cu-mulative degree of overall fat reduction and body contouring.
I have been informed and understand that temporary hyper-pigmentation/hypo-pigmentation on rare occasions may occur as a result of treatment.
I understand that there is a 24 hour cancellation policy for all appointments. Any no show or late cancellation/reschedule will be counted against my pre-paid sessions. I understand there are no refunds.
Confirmation
By checking this box, I confirm that the answers to this questionnaire are true and correct to the best of my knowledge. I also confirm that the staff explained the treatment(s) and answered my questions.
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Date of Birth
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Lipo Laser is one of the tools that we can use to help you reach your goals and the real advantage of this technology lies in the fact that we can specifically target a trouble area. Once the fats have been released from the cell they can be used by the body as a fuel source. Dietary and lifestyle changes are encouraged to help support the goals of treatment.
Ensure Your Best Results
For optimal results drink lots of water before and after treatments to help liquefy the fat. The fat cells are filled with triglycerides and this is helpful in making the content thinner so it is easier to excrete. Nothing by mouth except water 2 hours before. You can eat immediately after the treatment. Remember that after the treatment the pores are open. Do not consume anything high in carbs, sugar or fat for 24 hours. Avoid alcohol for 24 hours because your body wants to process sugar from alcohol before the glycerol from the fat cell. Do 10 minutes on the whole body vibration plate in order to accelerate the removal of the released fat by helping with lymphatic drainage. Some people will do 20 to 30 minutes of cardio on their own in addition and they always report that they lost even more inches in the 24hr period. Not everyone follows these guidelines and we understand if you don’t. You will still get results. BUT, for optimal results if you follow the above recommendations you will see considerable progress in your laser lipo journey.
What to Wear
We recommend that women wear a sports bra and yoga pants. Men should wear briefs that are a little more form fitting.
Risks:
I have been informed and I understand that temporary hyperpigmentation / hypopigmentation on rare occasion may occur as a result of treatment.
Consent for Treatment and Release of Liability
By signing this agreement I understand that I am beginning a series of laser lipo treatments to help reach my goals of body contouring and spot fat reduction. I understand that individual results may vary and that I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results. I understand that there are no guarantees or assurances that the program will be successful. I realize there may be pre-existing medical conditions that can preclude me from seeing optimal results. Because laser lips treatments should not be performed under certain medical conditions, I affirm that I have stated all of my known medical conditions, and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my medical profile. By signing this agreement, I release the spa/clinic, manufacturer and licensee end-user from any and all liability regarding this treatment and do so understanding that results can vary from one individual to the next. I have read and fully understand this consent form. My questions have been answered to my complete satisfaction. My signature herein constitutes my acknowledgment that I am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf ).
By checking this box I acknowledgmethat I am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf ).
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