Body Sculpting

(Branch - Reading)

First Name *

Last Name

Date of birth (DD/MM/YYYY) *

Phone *

Email *

Gender *

Male

Female

Other

Address

Street Address *

City *

State *

Postal code *

How many hours do you sleep per night?

How often do you exercise?

On a scale of 1 (low) to 10 (high) how would you rate your stress levels?

Occupation?

Age of children? (if any)

BMI Calculation

Please handover the device to your consultant

Height (In Inches)

Weight (In Kg)

Waist Size (In Inches)

Thigh Size (Inches) - For Bum Lift or Thigh Treatments only

Arms Size (Inches) - For Bingo Wing Treatments onlyThigh Size (Inches) - For Bum Lift or Thigh Treatments only

Nutrition

Please indicate the frequency of these foods consumed on a weekly basis:

Sugar

Spicy Foods

Takeaways

Snack foods

Salty food

Fast foods

Please indicate the quantities of fluid consumed on a daily basis

Water

Tea

Coffee

Fizzy Drinks

Juices

Alcohol

Colas

Do you have any specific dietary requirements ?

Health / Medical

Please list all medications that you have been prescribed by your GP:

Please list any non- prescriptive medication:

Health / Medical cont.

Have you ever had any surgery or undergone plastic surgery?

If yes, When?

Where on your body?

What information can you provide about the procedure?

Have you undergone treatment from a dermatologist/ skin peels/ botox /dermal filler/ threads/ IPL or laser?

If yes, When?

What type of treatment?

What information can you provide about the procedure?

Have you ever suffered with any gynaecological abnormalities, pelvic floor or pregnancy complications?

If yes, when you suffered

What type of treatment(s)?.

What information can you provide about the procedures?

Describe in detail (using product brand names) exactly how you are presently caring for your skin:

What is your specific concerns ?

Have you ever received Cavitation, Radio Frequency, Shockwave therapy, Cryolipolysis or HIFU on your face or body previously?

What were the results?

What are your expectations of your chosen treatment ?

Exercise

When did you last exercise and what muscle groups did you target?

What are your concerns?

What are your concerns?

Have you ever received any body treatment previously, if so please state treatment name(s) and date(s)?.

What were the result?

What are your expectation of your chosen treatment?

Client Release

Absolute Contra-indications
Pregnancy, recent pregnancy or breast feeding Cardiac conditions
Vascular Diseases
Pacemakers/Implanted Defibrillators/Reveal Devices
Thrombosis or Thrombophlebitis
Prescribed anti-coagulant medications Steroid medication
Uncontrolled Blood Pressure
Transplant patients

Post Treatment Recommendations
• Do not exercise the treated area for 48 hours

Possible Side Effects
Slight redness in treatment area Occasional minor muscle soreness • Possible abdominal discomfort (3D Powerform V)
Active Cancer patients and Cancer treatment Tumours
Metal prosthetics/pins and piercings
Diabetes
Epilepsy
Auto-immune conditions/immunosuppression Inflammation or infection in the treatment area Fragile skin
Skin thinning medication

Cavitation - possible side effects are redness,
bruising and skin sensitivity
Transplant surgery
Kidney or liver impairment
Only one kidney
Excess alcohol

Radio Frequency - possible side effects are skin
sensitivity, redness, scabbing, blistering
History of Keloid scarring
Photosensitive medication
Skin thinning medication
Recent skin peeling

Cryolipolysis - possible side effects are redness,
bruising, blistering, numbness, paradoxical
adipose hyperplasia, freeze burn
Transplant surgery
Skin thinning medication
Excess alcohol
Water retention
Raynauds

Shockwave Therapy - possible side effects are
swelling, haematoma, petechiae, discomfort
Coagulation disorders
Osteoporosis
Cortisone therapy

I certify that the above statements are true and correct and I having been advised by completely understand the implications of the treatment that I will be receiving, including the listed side effects. At no time have I been misled or badly informed by the above mentioned therapist or company. Any falsifications of information submitted by myself could be detrimental to my health and success of my treatment, and the company will not be held liable. I have been advised that I may experience possible discomfort during the treatment. I hereby authorise and direct them to administer the prescribed process and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowledgement that:

(1) I have read, understood and fully agree to the foregoing and I have received the post care treatment information above.

(2) Give consent to the proposed treatment process that has been satisfactorily explained to me and I have all the information that I desire.

(3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any claims that I have or may have in the future in connection with the described treatment.

I give consent for my photos to be used for marketing/ advertising purposes

Yes

Signature *

Clear

Our aim to provide incredible results in affordable prices.

Additional Comment