Appointment Check-In | Truebeautybydee

TrueBeautybydee Body Sculpting & Aesthetic's Intake form

First name

Last name

Address

Birthday

Month

Day

Year

Medical History

Do you have any chronic medical conditions that we should know about?

Yes

If yes, please list:

Are you currently taking any medications?

Yes

If yes, please list:

Do you have any allergies to oils, lotions, or ointments?*

Yes

(Allergies) If yes, please explain

Do you have type 1 or type 2 diabetes?

Yes

Do you have any known kidney or liver disorders?

Yes

If yes, please list:

Do you have photosensitivity to sun exposure?

Yes

Do you currently have cancer?

Yes

If yes, are you currently on chemotherapy?

Have you had cancer in the past 12 months?

Yes

Do you have any thyroid problems?

Yes

Do you have high blood pressure?

Yes

Do you have any cardiovascular conditions?

Yes

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?

Yes

If yes, please list:

What concerns would you like addressed today?

Do you want to lose body fat?

Yes

If yes, from what area:

Do you want to tighten skin on your body?

Yes

If yes, from what area:

(Female clients) Are you currently pregnant or nursing?

Yes

When was the first day of your last menstrual cycle?

Please list your regular exercise habits:

How many ounces of water do you drink daily?

I understand and agree that TrueBeautyByDee Body Sculpting & Aesthetics is not liable for personal injury, illness, or any other condition or side effects (including an injury, illness, death, conditions, Infections, and side effects from filler. Once you book your appointment you are agreeing to the terms and conditions. If any of the terms or Agreement is disclosed with any individuals outside of TrueBeautybydee You can be sued for defamation.

I understand that I can't take any legal action against TrueBeautyByDee Body Sculpting & Aesthetics.

Please sign your Signature Below in the box if you "Agree to the terms"

Signature

TD

IMPORTANT NOTICE (PLEASE READ & FILL INTAKE FORM) * THIS IS REQUIRED

Welcome to TrueBeautybydee

Please complete the Intake form. Once you have completed all the required steps, click "submit" and then proceed to click "Check-In".

Self Check-In