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Booking
About Us
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Booking
About Us
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Home
Sublime Lipo Consultation
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Do you have any allergies to latex, medications, herbal or natural supplements? If yes, please explain
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Do you have or had, any changes in medical history recently? If Yes, please explain
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Do you have Hearing aids, Pacemaker or Hormone Pellets (where), or metal/medical devices implanted? If yes, please explain
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Do you have type 1 or 2 Diabetes?
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Please list all current Medications including Vitamins.
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Do you have or have you had Cancer in the last 12 months
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Do you have a Thyroid Problem?
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Do you have High Blood Pressure or Cardiovascular conditions?
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Women Only, are you currently pregnant or nursing?
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Current Weight
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Current Height
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Which applies to you?
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Epilepsy
Loss of Normal Skin Sensation
Neck/Back Problems
Gallbladder Removed
History of Gallstones
History of Liver Problems
None of the Above
Are you Currently Dieting? If yes, please explain
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History of Colon: Problems including protruding/distended belly? If yes, please explain
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Have you had any surgeries?
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Infections Tumors Thrombosis/Phlebitis?
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Skin Diseases Autoimmune Disease?
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How many glasses of water do you usually drink?
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How many cups of coffee do you usually drink?
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Recreational Drugs (narcotics)?
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How much alcohol do you usually drink?
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How often do you eat fast food?
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How much carbonation (ex. soft drinks) do you usually take?
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Do you use tobacco?
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How is your stress level?
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I agree, to give consent to allow Sublime Body Med Spa staff members to consult with & evaluate me in order to determine if I am a good candidate for the Non-Surgical Lipo Services. I understand that photographs and measurements will be taken and kept in my file. I agree that these forms have been completed truthfully and to the best of my knowledge/abilities. Sign/Print your Legal Full Name
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Today's Date
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7311 S. Hulen St, Fort Worth, Texas
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sublimebodyspa@gmail.com
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