Intake Form

Client Information

Full Name:

Date of Birth:

Phone Number:

Email:

Emergency Contact Name & Phone: (optional)

How did you hear about Sculpted Body Contour?

Communication Preferences

Preferred Method of Contact (choose one):

I consent to receive appointment reminders, treatment recommendations, and follow-up messages using my selected contact method.

Service Interest

Body or Face:

Primary Focus Areas:

Timeline / Reason for Treatment:

Goals & Concerns

BODY GOALS:

Slim & Sculpt — fat reduction, body contouring, cellulite smoothing

Tone & Restore — muscle toning, postpartum support

Detox & Tighten — skin tightening, bloating/water retention, lymphatic detox support

FACE GOALS:

Lift & Define — lifting/firming, sculpted jawline, puffiness reduction

Smooth & Renew — fine lines/wrinkles, texture refinement, skin tightening

Clear & Glow — acne/congestion, brightening/glow

Medical & Health History

Chronic Condition

Thyroid / Hormonal Imbalance / PCOS

Diabetes

Autoimmune Condition

Heart Condition / High Blood Pressure

Liver or Kidney Condition

Circulatory / Vascular

History of Blood Clots

Varicose Veins

Neurological / Structural

Epilepsy / Seizures

Vertigo

Metal Implants / Pacemaker

Cancer

Cancer (current or past)

Female Health

Fibroids

Pregnant or Breastfeeding

Skin & Aesthetics

Skin Condition (Eczema, Rosacea, Psoriasis)

Fillers or Botox (within last 4 weeks)

Recent Surgery (within last 6 months)

Anything Else We Should Know?

Medications & Supplements

Check any that apply

Blood Thinners (including Aspirin, Fish Oil, Vitamin E)

Weight-Loss Medication (Ozempic, Wegovy, etc.)

Hormonal Birth Control or HRT

Supplements, Vitamins, Herbs, Teas

Other Prescription Medications? (optional)

Lifestyle & Metabolic Health

Check all that apply

I drink less than 4 cups of water daily

I experience frequent bloating or digestive issues

I have high stress or poor sleep

I follow a restrictive diet or have low physical activity

Body-Specific Questions

Check all that apply

I retain water easily

I bruise easily

I am sensitive to heat or pressure

I am currently on my menstrual cycle

Face-Specific Questions

Check all that apply

I experience facial puffiness

I clench or grind my teeth

I have sensitive or reactive skin

I have a history of acne or congestion

I have had a recent peel, microneedling, laser, or facial procedure

If you checked the last one, please explain: (optional)

Previous Experience

Check all that apply

I have had body sculpting before

I have had facial sculpting before

If yes, please list treatments and results: (optional)

Consent, Acknowledgment & Liability Waiver

I understand that services are non-invasive, non-medical cosmetic and wellness services. They 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. I 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.

I consent to before-and-after photos for progress tracking and educational/marketing purposes. (Photo will not be used without approval first)

Full Name (acts as signature):

Date:

Sculpted Body Contour

New Client Intake Form

Every treatment begins with understanding you — these questions help us design a sculpting experience that aligns with your lifestyle and supports your transformation inside and out.