Weight Loss Patient Intake

Name *

Date *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone (Cell) *

Email *

Date of Birth *

Age *

Height *

Estimated Weight *

Ideal Weight *

Are you taking any medications/supplements?

No
Yes

Are you pregnant, breastfeeding, or have active cancer?

No
Yes

Any known Shellfish allergies?

How did the previous methods work for you?

Self-Image

Selected Value: 1

Energy Level

Selected Value: 1

Quality of Sleep

Selected Value: 1

How Important It Is For You To Resolve Your Health Concerns

Selected Value: 1

This consent to treatment form explains the risks and benefits of the Contour Light treatments. Patient understands the following:

1. Results vary greatly from person to person. No result is guaranteed.
2. Contour Light is a treatment intended to be implemented in conjunction with a modification in diet and lifestyle as part of a complete protocol. The recommended diet and lifestyle is a critical part of the program and are essential in achieving the maximum results.
3. Temporary hyper pigmentation/hypo pigmentation (changes in skin color) on rare occasion may occur as a result of treatment.

SIGNATURE

By signing below, patient agrees that provider listed above may perform the Contour Light procedure for the purpose of body contouring. Patient understands and accepts the risks listed above and agrees that all information provided on this form is true and correct to the best of patient’s knowledge.

Print Name *

Date *

Patient Signature *

Weight

BMI

Body Fat %

Skeletal Muscle %

Body Age

Resting Metabolism

Visceral Fat Level

This consent to treatment form explains the risks and benefits of the Contour Light treatments. Patient understands the following:

SIGNATURE

Phone

Email

Follow Us

Address

Business Hours

Get the adjustment of a lifetime

Pay only $79 for your first Contour Light® session

Are you ready to achieve your weight loss goals?