Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Birth *Phone Number *Email *Emergency Contact Name & Number *How did you hear about us?Word Of MouthWebsiteBusiness CardsPlease check any conditions that apply to you.Heart disease or pacemakerHigh blood pressureLow blood pressureBlood clots or thrombosisCirculatory problemsDiabetes (Type I or II)Cancer (current or past)Autoimmune disorderThyroid disorderHormonal imbalanceKidney or liver conditionsEpilepsy or seizuresHepatitis (A, B, or C)HIV/AIDSMetal or electronic implantsHernia or hernia repairNerve damage or neuropathySkin disorders (eczema, psoriasis, etc.)Respiratory issues (asthma, COPD, etc.)Chronic pain conditionRecent infectionsRecent surgery (within 6 months)Blood disorder (anemia, hemophilia, etc.)Other (please explain):Please explain any conditions checked aboveAre you pregnant? *YesNoAre you breastfeeding? *YesNo before? Today's you Are you currently on your menstrual cycle? *YesNoAre you currently taking medication?YesNoIf yes, please list* Are you taking any herbal supplements or vitamins?YesNoIf yes, please list* Do you have any known allergies (medications, latex, skincare products, etc.)? *YesNoIf yes, please list* Are you currently exercising? *YesNoIf yes, how often* Are you following any diet or nutrition plan?YesNo* What areas would you like to target with body contouring? What are your primary goals for this treatment?* Have you had any body contouring or cosmetic treatments before? *YesNoIf yes, which type(s) and when? * Any recent cosmetic procedures (laser, injectables, etc.)? *YesNoIf yes, please list:Consent & Acknowledgement *By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that results may vary and that this treatment is not a substitute for medical advice or weight loss. I agree to follow all pre- and post-treatment instructions given by my technician. Today's Date *Submit