Sublime Lipo Consultation

Full Name *Please fill the required field.

Date of Birth *Please fill the required field.

Email *Please fill the required field.

Phone Number *Please fill the required field.

How did you hear about us? *Please fill the required field.

What is your main area(s) of focus/your problem area(s)? *Please fill the required field.

Do you have any chronic medical condition(s) which we should know about? If yes, please explain *Please fill the required field.

Do you have any allergies to latex, medications, herbal or natural supplements? If yes, please explain *Please fill the required field.

Do you have or had, any changes in medical history recently? If Yes, please explain *Please fill the required field.

Do you have Hearing aids, Pacemaker or Hormone Pellets (where), or metal/medical devices implanted? If yes, please explain *Please fill the required field.

Do you have type 1 or 2 Diabetes? *Please fill the required field.

Please list all current Medications including Vitamins. *Please fill the required field.

Do you have or have you had Cancer in the last 12 months *Please fill the required field.

If yes, are you currently on chemotherapy?

Do you have a Thyroid Problem? *Please fill the required field.

Do you have High Blood Pressure or Cardiovascular conditions? *Please fill the required field.

Women Only, are you currently pregnant or nursing? *Please fill the required field.

Current Weight *Please fill the required field.

Current Height *Please fill the required field.

Are you Currently Dieting? If yes, please explain *Please fill the required field.

History of Colon: Problems including protruding/distended belly? If yes, please explain *Please fill the required field.

Have you had any surgeries? *Please fill the required field.

Infections Tumors Thrombosis/Phlebitis? *Please fill the required field.

Skin Diseases Autoimmune Disease? *Please fill the required field.

How many glasses of water do you usually drink? *Please fill the required field.

How many cups of coffee do you usually drink? *Please fill the required field.

Recreational Drugs (narcotics)? *Please fill the required field.

How much alcohol do you usually drink? *Please fill the required field.

How often do you eat fast food? *Please fill the required field.

How much carbonation (ex. soft drinks) do you usually take? *Please fill the required field.

Do you use tobacco? *Please fill the required field.

How is your stress level? *Please fill the required field.

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 *Please fill the required field.

Today's Date *Please fill the required field.

I agree with the Terms of Use and Privacy Policy and I declare that I have read the information that is required in accordance with Article 13 of GDPR.

CONTACT US

Book your session now!

Address

7311 S. Hulen St, Fort Worth, Texas

Phone

(817) 881-5010

Email

sublimebodyspa@gmail.com

Welcome to your elite center for aesthetic & precision wellness medicine. We redefine beauty.

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