Full Name:
Phone Number:
Email:
Emergency Contact Name & Phone: (optional)
How did you hear about Sculpted Body Contour? – Referral Instagram TikTok Facebook Yelp Google Ad
Communication Preferences
Preferred Method of Contact (choose one): – Text Message Email Instagram DM WhatsApp
Body or Face: – Body Sculpting Facial Sculpting Both Face & Body
Primary Focus Areas: – Abdomen Flanks Back Arms Thighs Glutes Jawline Cheeks Chin Neck Under-eye Full Face
Timeline / Reason for Treatment: – Maintenance / Wellness 4-6 weeks 8-12 weeks Special Event
BODY GOALS:
FACE GOALS:
This information ensures your safety and optimal results.
Are you currently under a medical care? – Yes No
If yes, please explain: (optional)
Medications & Supplements
Prescription Medications: (optional)
Hormonal Birth Control: (optional)
Blood Thinners: (optional)
Weight-Loss Medications (Ozempic, Wegovy, etc.) (optional)
Supplements, Vitamins, Teas, Herbs (optional)
Lifestyle & Metabolic Health
Daily Water Intake: – Less than 40oz 40-60oz 60-80oz 80+oz
Digestion: – Regular Bloating Constipation Irregular
Physical Activity Level: – Sedentary Light Movement Moderate Exercise Intense Training
Diet Style: – Balanced High Protein Low Carb / Keto Vegan / Vegetarian High Sodium Frequent Alcohol
Stress Level: – Low Moderate High
Sleep Quality: – Poor Fair Good
Do You retain water easily? (optional) – Yes No
Experience frequent bloating? (optional) – Yes No
Bruised Easily? (optional) – Yes No
Sensitive to heat or pressure? (optional) – Yes No
Currently on menstrual cycle? (optional) – Yes No
Do you experience facial puffiness? (optional) – Yes No
Do you clench or grind your teeth? (optional) – Yes No
Sensitive or reactive skin? (optional) – Yes No
history of acne or congestion? (optional) – Yes No
recent peels, microneedling, lasers, or facial procedures? (optional) – Yes No
If yes, please explain: (optional)
Have you had body sculpting before? (optional) – Yes No
Have you had facial sculpting before? (optional) – Yes No
If yes, please list treatments and results experience: (optional)
Consent, Acknowledgment & Liability Waiver
I understand that services provided by Sculpted Body Contour are non-invasive, non-medical cosmetic and wellness services and are not intended to diagnose, treat, cure, or prevent any medical condition.
I acknowledge that results vary and depend on individual factors including lifestyle, metabolism, hydration, and consistency. No specific results have been guaranteed.
I confirm that I have disclosed complete and accurate health information, including medical conditions, medications, supplements, and recent procedures, and understand that withholding information may increase risk.
I understand that temporary effects such as redness, swelling, bruising, tenderness, or sensitivity may occur and are generally temporary.
I voluntarily assume all risks associated with these services and agree to follow all pre- and post-care instructions provided.
To the fullest extent permitted by law, I release and hold harmless Sculpted Body Contour, its owner, and staff from any claims or liability arising from the services provided, except in cases of gross negligence or willful misconduct.
I confirm that I am at least 18 years of age and that I have read, understood, and agree to this consent.
Full Name (acts as signature):
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