About this template
Streamline your initial patient assessments with this comprehensive Body Contouring Consultation form template. Designed specifically for plastic surgery practices, medical spas, and aesthetic clinics, this form captures vital patient information, medical history, lifestyle factors, and specific aesthetic goals before the first appointment. By collecting these details in advance, your clinical team can review candidacy for procedures like liposuction, tummy tucks, or non-invasive fat reduction safely and efficiently.
Built for seamless patient experience, the form covers essential health markers including current medications, known allergies, medical conditions, and previous surgical history. It also incorporates structured sections for lifestyle habits such as diet, exercise routines, and pregnancy or breastfeeding status, which are critical for determining treatment eligibility. Finally, built-in acknowledgment and consent checkboxes ensure your practice maintains thorough records from day one.
Powered by Doc2Form, you can instantly convert this template into a fully functioning Google Form, ready to share via direct link, embed on your website, or have patients fill out on a tablet in your waiting room. It eliminates paper clutter and helps your practice maintain a professional, organized intake workflow.
Key features
- Capture complete patient medical history and lifestyle habits securely
- Screen for procedure eligibility, contraindications, and pregnancy status
- Collect detailed aesthetic goals and target treatment areas
- Include built-in acknowledgments and treatment consent acceptance
- Mobile-friendly layout for easy completion on phones, tablets, or desktops
Use cases
Initial virtual or in-person plastic surgery consultations
Medical spa pre-treatment intake for non-invasive body sculpting
Tracking patient goals and baseline metrics prior to fat reduction se…
Tracking patient goals and baseline metrics prior to fat reduction series
Gathering digital informed consent and health disclaimers
What this form collects
- Full Name (Short answer)Enter your first and last name as it appears on your government-issued ID.
- Date of Birth (Date)Enter your date of birth.
- Gender (Multiple choice)Select the gender you identify with.
- Email Address (Short answer)We will use this to send your consultation notes and appointment confirmations.
- Phone Number (Short answer)Enter your primary mobile number for appointment reminders.
- Home Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Emergency Contact Name & Relationship (Short answer)Provide the name and relationship of someone we can contact in case of an emergency.
- Emergency Contact Phone Number (Short answer)Enter the best phone number to reach your emergency contact.
- How did you hear about us? (Dropdown)Select your primary referral source.
- What is your main aesthetic goal? (Paragraph)Describe the specific areas of your body you would like to treat or improve.
- Are you currently following a specific diet plan? (Short answer)Briefly describe any dietary regimen you follow (e.g., keto, low-calorie, plant-based).
- Pregnancy Status (Multiple choice)Are you currently pregnant or planning to become pregnant in the near future?
- Breastfeeding Status (Multiple choice)Are you currently breastfeeding?
- Do you engage in regular exercise? (Short answer)Describe your weekly exercise routine, including frequency and types of activity.
- Current Medications & Supplements (Paragraph)List all prescription medications, OTC drugs, herbal supplements, and vitamins you currently take.
- Known Allergies (Short answer)List any allergies to medications, latex, adhesive tape, or topical anesthetics.
- Medical Conditions Checklist (Checkboxes)Select any conditions you have been diagnosed with or treated for in the past.
- Acknowledgment and Truthfulness (Multiple choice)I confirm that all medical history and personal information provided above is accurate and complete to the best of my knowledge.
- Body Contouring Consultation Consent (Multiple choice)I understand that a consultation is required to determine candidacy and that results may vary.
- Digital Signature (Short answer)Type your full legal name to serve as your electronic signature.
- Date Signed (Date)Enter today's date.
FAQ
How do I share this consultation form with my patients?
Once you convert the template using Doc2Form, you can share the Google Form link via email or SMS before their appointment, embed it directly on your clinic website, or have patients complete it on a tablet in your office.
Can I customize the medical questions and procedure options?
Yes! Because the template lives entirely in your Google Drive as a standard Google Form, you can easily add, remove, or edit any questions to match your specific clinic offerings.
Is this form mobile-friendly for patients?
All Google Forms automatically adjust to fit smartphones, tablets, and desktop computers, ensuring your patients have a smooth experience filling it out from any device.
How does Doc2Form help me set up this form?
Doc2Form instantly generates this ready-to-use template directly in your Google Workspace account with a single click, saving you hours of manual form building.
How can I collect patient signatures securely?
You can include a text field for typed legal names and date stamps to confirm digital acknowledgment, or pair the form with electronic signature add-ons available for Google Workspace.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.