About this template
Streamline client onboarding at your medical spa, body contouring clinic, or aesthetic practice with this comprehensive Fat Cavitation Client Intake Form. Designed specifically for ultrasound fat cavitation and body sculpting procedures, this form collects essential client details, comprehensive medical history, lifestyle factors, and specific body composition goals before treatment begins.
Before administering body contouring procedures, practitioners must screen clients for contraindications such as implanted medical devices, liver or kidney disorders, pregnancy, and other health conditions. This digital intake questionnaire safely gathers all necessary medical disclaimers and client consent in one organized place. By switching to a digital workflow powered by Doc2Form, you eliminate messy paper clipboards, reduce administrative check-in friction, and ensure your clinic has all required treatment acknowledgments securely documented prior to the session.
Key features
- Screen for medical contraindications and health history instantly.
- Collect specific body composition goals and target treatment areas.
- Gather digital informed consent and policy acknowledgments.
- Fully customizable questions to match your clinic's protocols.
- Accessible on any mobile device or tablet for easy lobby check-in.
Use cases
Medical spas offering ultrasound fat cavitation and radiofrequency sk…
Medical spas offering ultrasound fat cavitation and radiofrequency skin tightening.
Body contouring clinics tracking client baseline measurements and goals.
Aesthetic practitioners requiring pre-treatment medical waivers and h…
Aesthetic practitioners requiring pre-treatment medical waivers and history.
What this form collects
- Full Name (Short answer)Enter your first and last name.
- Birthday (Date)Enter your date of birth (MM/DD/YYYY).
- Residential Address (Paragraph)Enter your street address, city, state, and ZIP code.
- Phone Number (Short answer)Enter your primary mobile number for appointment reminders.
- Email Address (Short answer)Enter your preferred email address.
- Gender (Multiple choice)Select your gender identity.
- Emergency Contact Name and Phone (Short answer)Provide the name and phone number of someone we can reach in case of an emergency.
- How did you hear about us? (Dropdown)Select the option that best describes how you found our clinic.
- Are you currently pregnant or nursing? (Multiple choice)Fat cavitation is strictly contraindicated during pregnancy and lactation.
- Do you have any implanted medical devices? (Multiple choice)Examples include a pacemaker, defibrillator, or metal plates/pins in the treatment area.
- Do you have any kidney or liver disorders? (Multiple choice)These organs are responsible for processing released fat cells.
- Do you have diabetes, cardiovascular conditions, or high blood pressure? (Multiple choice)Select yes if you actively manage any of these conditions.
- Have you undergone chemotherapy or had cancer in the past 12 months? (Multiple choice)Please disclose any recent cancer treatments.
- List any current medications, medical conditions, or recent plastic surgery (Paragraph)Provide details if you answered yes to any medical conditions above or take regular prescription drugs.
- What are your primary body contouring goals? (Checkboxes)Select all areas you would like to target for fat reduction, skin tightening, or cellulite reduction.
- Describe your daily water intake and exercise habits (Paragraph)Drinking plenty of water is essential for flushing fat post-treatment. Please note your average daily water consumption in ounces.
- Client Acknowledgment and Signature (Short answer)By typing your full legal name below, you confirm that all information provided is accurate and that you consent to receive fat cavitation treatments.
- Date of Signature (Date)Enter today's date.
FAQ
How do I share this intake form with my clients?
You can easily share the form link via email confirmation, text message before their appointment, or by having clients fill it out on a tablet or device in your clinic waiting room.
Can I customize the medical questions for other treatments?
Yes! You can easily edit, add, or remove any questions using Google Forms to fit other aesthetic procedures like cryolipolysis, laser hair removal, or skin facials.
Is this form mobile-friendly for clients?
Absolutely. Google Forms automatically adjusts to look and function perfectly on smartphones, tablets, and desktop computers.
How do I collect client signatures for consent?
You can include a required acknowledgment checkbox confirming they agree to your clinic policies, or use a paragraph text field where they type their legal name as an electronic signature.
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.