CLIENT INTERVIEW FORM
Please tell us about yourself.
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mobile Number
*
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Gender
*
Male
Female
Height
*
ex: 5'8"
Weight (lbs.)
*
Goal Weight (lbs.)
*
Please write any concerns or issues you would like to share:
*
If none type "N/A"
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EXERCISE
Specify frequency and duration for each activity
*
Frequency (times per week)
Duration (how long each session is)
Cardio
Yoga
Pilates
Weight Training
None
Other
DIET
Are you on a specific diet?
*
Yes
No
If yes, please elaborate
How many ounces of water do you consume in a day?
*
Under 32 oz
32 oz - 64 oz
64 oz - 96 oz
96 oz +
Average Daily Caloric Consumption
*
Under 1,500
Under 2,000
Under 2,500
2,500 +
How many alcoholic drinks do you consume per week?
Please Select
0
1-2
3-4
5-6
7+
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WHAT ARE YOUR TREATMENT GOALS?
Check any item you'd like to address
FACE
Reverse signs of aging
Reduce wrinkles
Improve skin tone
Better definition
Lift cheeks
Neck
Turkey neck/sagging skin
Reduce wrinkles
Tighten double chin
DECOLETTE (NECK LINE)
Reduce wrinkles
Crepey skin
Please elaborate on above indicated areas of concern (if any):
TONING - Specify problem areas of the body for each item.
ARMS
LEGS
BACK
ABDOMEN
CHEST
HIP
Crepey Skin
Wrinkles
Hanging Skin
Loose Skin
FAT REDUCTION - Check any areas that apply
Arms
Abdomen
Thighs
Gluteus
Legs
Hips (love handles)
Calves
Back
CELLULITE - Check any areas that apply
Arms
Thighs (Front)
Thighs (Side)
Thighs (Back)
Gluteus
DEFINITION | CONTOUR - Check any areas that apply
Arms
Hips/Waist
Legs
Gluteus
Chest
Abdomen
Back
MUSCLE RELAX - Check any areas that apply
Neck
Back
Left Arm
Right Arm
Left Thigh
Left Calf
Left Hamstring
Right Thigh
Right Calf
Right Hamstring
PLEASE CHECK IF YOU HAVE ANY OF THE FOLLOWING CONDITIONS
*
Severe kidney disease (dialysis, kidney disease or if you only have one kidney) - applies to fat and cellulite treatments
Active Cancer, undergoing chemotherapy within the last 12-months - applies to fat and cellulite treatments
Severe diabetes. Loss of sensation (tingling) in the extremities or the skin.
Polyneuropathy (only applies to the legs)
Open or untreated abdominal hernia (No fat reductions over an open hernia).
Varicose veins
Pregnant
Botox treatment within 2 weeks
Filler treatment within 4 weeks
NONE OF THE ABOVE APPLY TO ME
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INFORMED CONSENT, RELEASE & INDEMNITY AGREEMENT
The Cryo T-Shock safely and effectively uses thermal shock to naturally destroy fat cells without any damage to the skin. The Cryo T-Shock breaks down fat cells, which your body naturally flushes out through the bloodstream and the lymphatic system in days to weeks following the treatment. Cryo T-Shock also helps reduce the appearance of fine lines and wrinkles by stimulating collagen and elastin production while tightening muscles. The Cryo T-Shock is also beneficial for facial toning and lifting. Protocols will be discussed and or adjusted during consultation based on recommendations and client needs. I understand that the results of Cryo T-Shock fat and/or cellulite reduction treatment (hereinafter referred to as “T-Shock Treatment”) may vary depending on many individual factors, including but not limited to: medical history, prior treatments of the area being treated, skin type, compliance with pre- and post-care instructions and individual responses. I understand that for purposes of fat/cellulite reduction and/or skin toning I must maintain good dietary habits, maintain sufficient intake of water and participate in light physical activity as well as comply with all items, instructions and guidelines discussed during consultation prior to T-Shock Treatment. I have been informed and understand that, following T-Shock Treatment, a vigorous workout for at least thirty minutes is required on the same day in order to facilitate lymphatic drainage. I understand that any procedure involves risk. Known risks of T-Shock Treatment may include, but are not limited to: redness, swelling, irritation, skin reaction, or increased heart rate. Some individuals may experience delayed onset muscle soreness from treatments on the stomach due to unintentionally engaging the abdominals. Such muscle soreness ordinarily disappears later the same day. T-Shock Treatment may also entail risks not presently known or knowable. Cryo T-Shock treatment should not be performed under the following conditions: Cryo T-Shock should not be applied over inflamed, infected, or swollen areas of the skin. Cryo T-Shock should not be applied over/near cancerous areas or on clients with active cancer or undergoing chemotherapy. Cryo T-Shock should not be used on clients who suffer from Kidney Disease. Cryo T-Shock should not be used on clients undergoing dialysis. Cryo T-Shock should not be used on clients who are pregnant. Cryo T-Shock should not be used on clients with varicose veins. Cryo T-Shock facial applications should not be used on clients who have had Botox treatments within 14 days or Filler treatments within 30 days. Cryo T-Shock should not be used on clients who suffer from severe diabetes where sensation has been lost in the skin. By signing this agreement, I acknowledge and represent that, to the best of my knowledge, I do not have any of the foregoing conditions. I further acknowledge that I have been honest and forthright about my medical history and am healthy to receive T-Shock Treatment. I am not pregnant, nor do I have any other disease or condition that may be negatively impacted by T Shock Treatment.
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COVID-19 WARNING
I understand that COVID-19 has been declared a worldwide pandemic by the World Health Organization. The virus that causes COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. I am aware that T-Shock Treatment may entail proximity to other individuals and human contact and therefore may increase my risk of becoming infected with the Coronavirus and of contracting COVID-19. By signing this agreement, I voluntarily agree to assume all risks of undergoing T-Shock Treatment, whether included among the known risks listed above, or whether such risks are presently known, unknown or unknowable, including risks related to contracting COVID-19. I accept sole responsibility for any injury, illness, damage, loss, claim, liability, or expense of any kind that I incur in connection with T-Shock Treatment. I agree to unconditionally and forever release, covenant not to sue, discharge, and hold harmless Abundant Health Physical Medicine’s officers, directors, employees, agents, affiliates, representatives, successors and assigns from any and all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to T-Shock Treatment. I further agree that if any third-party brings legal or equitable claims that in any way relate to or arise from T-Shock Treatment performed on me against the Company and/or the Company’s officers, directors, employees, agents, affiliates, representatives, successors and assigns (the “Indemnified Parties”), I will indemnify the Indemnified Parties for any liability or litigation costs incurred by Indemnified Parties as a result of such claims.
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PHOTOGRAPH RELEASE
I give permission for photographs and other audio-visual and graphic materials to be used for marketing, education-promotion purposes. Although the photographs or accompanying material will not contain my name or any other identifying information, I am aware that I will not be identified in the photos.
Initials if you give permission otherwise please leave blank.
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ACKNOWLEDGEMENT
I understand each person has a different response to the T-Shock Treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. I agree to have my photograph taken to document my results and will not be used for marketing unless agreed upon (see above).
Initials
*
BY SIGNING BELOW, I ACKNOWLEDGE AND CERTIFY THAT I HAVE READ AND UNDERSTAND THE "CONSENT, RELEASE AND INDEMNITY AGREEMENT" FOR THIS TREATMENT, AND THAT I AM SIGNING IT VOLUNTARILY. SHOULD ANY PAIN OR DISCOMFORT OCCUR I WILL IMMEDIATELY NOTIFY THE ABUNDANT HEALTH PHYSICAL MEDICINE STAFF. I UNDERSTAND THAT I MUST BE AT LEAST 18 YRS OLD TO PARTICIPATE IN THIS TREATMENT. I UNDERSTAND THAT ALL SALES ARE FINAL AND REFUNDS ARE NOT PERMITTED.
Signature
*
OFFICE USE ONLY | ADICELL THERMOGRAPHIC FILM INTERPRETATION
Light
Moderate
Severe
Presence of hardened fat on abdomen
OFFICE USE ONLY | ADICELL THERMOGRAPHIC FILM INTERPRETATION
Edemous
Fibrotic
Sclerotic
Cellulite Analysis
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