Client Intake Form

Client Intake Form

Forever Pretti Body Studio
Name *
Phone *
Address *
City/State/Zip *
Email *
example@example.com
Date of Birth *

Month Day Year
Date
Occupation *
Emergency Contact *
Phone *
The following information will be used to help plan safe and effective sessions. Please answer the questions to the best of your knowledge.
Date of Initial Visit and Procedure selected *

Month Day Year
Date
1. Have you had this procedure before? *
If yes, how often? *
2. Do you have any difficulty lying on your front, back, or side? *
If yes, please explain *
3. Do you have any allergies to oils, lotions, or ointments? *

Yes No If yes, please explain
4. Do you have sensitive skin? *

Yes No
5. Are you wearing contact lenses, dentures, or a hearing aid? *
6. Do you sit for long hours at a workstation, computer, or driving? If yes, please describe *
7. Do you perform any repetitive movement in your work, sports, or hobby? If yes, please describe *
8. Do you experience stress in your work, family, or other aspect of your life? If yes how do you think it has affected your health? *

Muscle tension Irritability Anxiety Insomnia None
9. Is there a particular area of the body you would like to see improvement? *

No Yes
10. Do you have any particular goals in mind for this session? If yes, please explain *
Medical History
In order to plan a session that is safe and effective, we need some general information about your medical history.
11. Are you currently under medical supervision? Yes or No? If yes, please explain *
12. Do you see a Chiropractor? If yes, how often? *
13. Are you currently taking any medication? Yes or No *
If yes, please list *
14. Please check any condition listed below that applies to you:
By initialing here I attest *
that I am NOT pregnant. *

pacemaker or other electronic device plastic, bone cement, or any large metal contagious skin condition open sores or wounds atherosclerosis easy bruising phlebitis recent accident or injury deep vein thrombosis/blood clots recent fracture joint disorder/rheumatoid/arthritis/tendonitis Recent surgery osteoporosis artificial joint epilepsy sprains/strains headaches/migraines current fever cancer swollen glands diabetes allergies/sensitivity decreased sensation heart condition back/neck problems high or low blood pressure Fibromyalgia circulatory disorder edema Varicose Veins Pregnancy and/or nursing None
Medical History Continued
Please explain any condition that you have marked *
15. Is there anything else about your health history that you think would be useful for your practitioner to know to plan a safe and effective session for you? *
16. Please list All medications including supplements and herbs that you are currently taking. *
I attest I am 18 years or older and understand that the services I receive are provided for the basic purpose of body contouring and that individual results may vary. If I experience any pain or discomfort during this session, I will immediately inform the body sculpting practitioner. I further understand that body contouring should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician or other qualified medical specialist for any mental or physical ailment that I may have. I understand that body sculpting practitioner are not qualified to, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of this session should be construed as such. Because body contouring should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. I agree to keep the body sculpting practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the part of the body sculpting practitioner or Forever Pretti Body Inc. should I fail to do so. I agree to hold harmless Forever Pretti Body Inc., its employees and representatives.

Fees & Cancellations: I understand that there are NO REFUNDS for services or products. Payment is

required in full prior to initial treatment. Costs do not include future visits unless expressed otherwise. Packages must be paid in full prior to initial treatment and are non-refundable.

If you need to cancel for any reason, a 24 hour notice is required or a $50 fee will incur that will be collected prior to treatment
Client's Initial *

Clear
Picture & video usage: Before, during, & after pictures & videos may be taken to document

treatments. These pictures or videos become Forever Pretti Body Inc. sole property and may only be used for promotional and/or educational purposes.
Client's Initial

Clear
Date

Month Day Year
Date
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Medical History

Medical History Continued

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