Body Contour Wrap Patient Intake
Please Complete the Form Below
Full Name
*
Date
*
Address
*
City
*
State
*
Postal code
Home Phone
*
Cell Phone
*
Email
*
Date of birth
*
How Did You Hear About Us
*
I agree to
terms & conditions
provided by the company. By providing my phone number, I agree to receive text messages from the business.
Please Check If You Have Any of the Following:
An Infectious Disease
High Blood Pressure
Diabetes
Allergic or Sensitivity to Iodine or Shellfish
Osteoporosis
Edema
Heart / Circulation Issues
Varicose Veins
Skin Problems
Sprains / Strains
TMJ
Cancer
Epilepsy
Arthritis
Numbness
Fibromyalgia
Any Other Allergies?
Please use the space below to provide additional information concerning any items checked above or any other health-related conditions you currently have or have experienced in the past which would impact your service today or if there is anything you want us to know before we begin with your body wrap:
What are the personal goals you are trying to achieve through the Body Contour Session?
How many inches would you like to lose?
What areas of your body are you looking to achieve inch loss (tummy, arms etc.)?
Present Weight
*
Height
*
Desired Weight
*