BODY WRAP FORMS | Reinventu

BODY WRAP CONSENT FORM

Have you consumed at least 3 glasses of water today prior to treatment?

Yes

No

How did you hear about Reinvent U Boot Camps LLC?

Check if you have or had any of the following:

Pregnant/Brestfeeding

HIV/AIDS

Bleeding Disorders

High Blood Pressure

High Cholesterol

Liver Disorders

Skin Disorders

Respiratory Disorders

Nerological Disorders

Cardiac Disorders

Lymphatic Disorders

Psychological Diagnosis

Diabetes

Pace Marker or Devices in Body

Metals in Body

Seizures

Cancer

Acute illness (cold/flu/diarrhea/etc.)

Other:

Please explain if you checked any items above.

Describe all surgeries and the year you received them:

List all allergies and your reactions:

List all medications/herbs/supplements currently or recently taken:

List any medical or non-medical condition your technician should be aware of:

Specific Appearance problems and treatment goals:

What are your over-all body slimming & contouring goals?

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?

Please list your last date of menstruation:

*Do not schedule Non-Invasive Lipo or RF Skin Tightening treatment during your cycle! (Abs Only) Cycle will become heavy.

1321A Bedford Avenue
Pikesville, MD 21208

410-602-UFIT (8348)

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