Please enable JavaScript in your browser to complete this form. - Step 1 of 4Name *Email *DateTO BEST PROTECT YOUR HEALTH AND THE HEALTH OF OTHERS, PLEASE FILL OUT THIS FORM WEEKLY BEFORE YOUR MASSAGE SESSION. THANK YOU.Have you been tested for COVID-19?Yes NoWhen did you get tested?What were the results?Have you recently been in places with high infection rates? *YesNoPlease explain.Please check of you are experiencing any of the following as a NEW PATTERN:FeverChillsCoughSore throatNasal/sinus congestionLoss of taste or smellFatigueShortness of breathDiarrheaSudden muscle sorenessRash or skin lesions?Digestive upsetDo you have any discomfort with exertion or exercise? *I declare that the information provided above is true and accurate to the best of my knowledge.SignatureDateNextBody ContouringIntake FormName *DateAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail *PhoneDOBAgeWeightHeightSexFemaleMaleHow did you hear about us?Emergency Contact InformationName *PhoneAre you currently under the care of a physician?YesNoDo you frequently exercise?YesNoHow often do you exercise1-2 times per week3-4 times per weekmore than 4 times per weekWhat body areas would you like us to focus on?What are your weight loss expectations with us?Anything else that you want to accomplish in the blank box. At the end of your treatment, measurements will be taken again to ensure improvement.NextMedical History & Treatment AgreementCOSTS: All treatments must be paid in advance and are non-refundable.Medical backgroundPlease check if you answer YES to any of these questionsAre you pregnant or nursing?Do you have any cancer or tumor?Do you have blood clotting?Do you have any contagious disease(s)?;Do-you-have-any-contagious-disease(s)?Do you have any cardiac problem(s)?Do you have any wounds not healed?Have you ever had internal bleeding?Do you have high or low blood pressure?Do you have any heart problems?Do you have any plastic or metal implants?Are you receiving any medications?Do you have melanoma?Are you epileptic?Do you have diabetes?Do you have tuberculosis?Do you have any internal device(s)?Do you have uterine cysts?Do you have any virus?Do you have any wounds on your skin?Do you have a transplant?Have you had any abdomen surgeries?Do you have any infections?Do you suffer from depression or anxiety?Where do you have any plastic or metal implants?Which medication are you receiving?Please list your medical information down below:Name of the clinic/hospital:Name of your doctor:Location:Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI agree and accept to continue these therapies under my full responsibility and I confirm I am over the age of 18. *YesNoSignature (copy)Date (copy)NextCLIENT RELEASE AND COMMITMENT FORMI AGREE TO THE FOLLOWING TERMS FOR MY Body Contour SERVICESI agree to keep all my appointments scheduled.I understand and acknowledge all missed appointments are not made up and non-refundable. I understand that I must cancel my appointment 12 hours prior or I will be charged for the full price of that appointment.I am aware that all files, photographs, and measurements are the property of V.VSpaI UNDERSTAND THAT V.V SPA IS NOT RESPONSIBLE FOR THE OUTCOME/RESULTS OF MY SURGERY. I MUST CONTACT MY DOCTOR FOR QUESTIONS REGARDING MY RESULTS. a. Example: lumps, excess fat, etc.Everything that happens in the appointment will not be shared.I give permission to V.V Spa to publish statistical data and photographs derived from my Body contour care service.IF I DO NOT AGREE, I CANNOT CONTINUE MY TREATMENT.Printed Name *DateSignatureWitnessPreviousSubmit
