BODY/FACIAL SCULPTING

CLIENT DATA FORM

PAGE 1 OF 2

Date: _______________ Birthday (Day/Month) ___ / ___

Name: _______________________________________________________________________
Address: ___________________________ City/State: ________________ Zip: __________
Primary Phone: _________________ Secondary Phone: ___________________________
Email: _________________________________________________________________________

How did you hear about us: ___________________________________________________

Would you like to be informed of upcoming promotions via email? YES NO

MEDICAL SCREENING AND CONTRA-INDICATIONS

Height: _________ Weight: _________

Current Types of Exercise: _____________________________________________________

Implanted Pacemaker YES NO HAVE YOU BEEN DIAGNOSED WITH:

Cardiac Conditions YES NO Cancer YES NO
Lupus Erythemalosus YES NO High Blood Pressure YES NO
Adrenal Suppression YES NO Heart Disease YES NO
Multiple Sclerosis YES NO Angina/Chest Pain YES NO
Metal Rods, Pins or Joints YES NO Stroke YES NO
Skin Disorders YES NO Osteoporosis YES NO
Implanted Silicon YES NO Osteoarthritis YES NO
Varicose Veins YES NO Rheumatoid Arthritis YES NO
Heavy Menstruation YES NO Sexually Transmitted Disease YES NO
Botox Use YES NO
Nursing Mother YES NO HAVE YOU EXPERIENCED THESE
Pregnancy YES NO SYMPTOMS IN THE LAST 3 MONTHS?
Const. Coronary Vessels YES NO A change in your health YES NO
High or Low Blood Pressure YES NO Nausea/Vomiting YES NO
Enclosed Infection YES NO Fever/Chills/Sweats YES NO
Hemophilia YES NO Numbness YES NO
Overactive Thyroid Gland YES NO Changes in Appetite YES NO
Diabetes (Insulin Use) YES NO Difficulty Swallowing YES NO
Kidney Malfunctions YES NO Bowel/Bladder Changes YES NO
Open Wounds YES NO Shortness of Breath YES NO
Skin Disease YES NO Dizziness YES NO
Contact Allergies YES NO Upper Respiratory Infection YES NO
General Infections YES NO Urinary Tract Infection YES NO
Blood Clots YES NO Surgery YES NO

4703 West Lovers Lane, Dallas 75209 (214) 352-8800 www.luxuryonlovers.com

 BODY/FACIAL SCULPTING
CLIENT DATA FORM
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DO YOU HAVE A HISTORY OF: How are you able to sleep at night?
Allergies/Asthma YES NO Fine __ Some Difficulty __ With Medication ___
Headaches YES NO Do you have a problem with: (Please check)
Bronchitis YES NO Hearing ___ Vision ___ Speech ___
Kidney Disease YES NO How many packs of tobacco do you smoke
Rheumatoid Fever YES NO each week? ________
Ulcers YES NO How long have you smoked? (If applicable)
Seizures YES NO ________________________
How many alcoholic drinks do you consume
Client Information: each week? ___________________
Date of last physical examination:
____________________
List medications currently using:
______________________________________________
______________________________________________

Consult with your doctor before receiving any Total Body Sculpting sessions if you have received
treatment for any of the conditions listed above. You should not receive sessions if you suffer
from any of the conditions listed above without the prior consent of a doctor. If you have a
history of any other medical condition, or if you are taking prescription drugs, you should consult
with your physician before using any LUXURY ON LOVERS services.

Our equipment is used to treat beauty problems only. Clients who suffer or have suffered in past
months from specific pathologies (organic, neurological or psychiatric diseases and/or skin
problems) must not be subjected to the sessions without the prior written approval of their
medical specialist.

CLIENT ACKNOWLEDGEMENT:

I have been fully informed and understand the use of Total Body Sculpting procedural
equipment, and I accept personal responsibility for my sessions. I understand that LUXURY ON
LOVERS and its staff are not liable for any personal injury caused in any way by the use of its
services or premises. I am aware that the results achieved by these sessions may vary from
person to person, and I acknowledge that no promises or guarantees have been made to me
regarding the results of my sessions.

Client Signature: _____________________________________ Date:_____________________

4703 West Lovers Lane, Dallas 75209 (214) 352-8800 www.luxuryonlovers.com