Welcome to Elite Body Contouring - Rosebery

Thank you for booking with Elite Body Contouring – Rosebery. Please fill in the below form to give us more information on how we can cater our services to your needs. It should take about 5-10 minutes

Your Details




Date of Birth:

Which Industry Do You Work In?


How Did You Hear About Us?

Activity & Lifestyle

On Average, How Many Hours of Sleep Do You Have Each Night?

On Average, How Often Do You Exercise Per Week?

On a Scale from 1 (low) to 10 (high), How Would You Rate Your Stress Levels?

If You Have Children, How Old Is Your Youngest Child?

Home Skin Care Regime

Describe In Detail (Including Product Names) Your Current Home Skin Care Regime

Health & Medical

Name of Doctor/Personal Physician (if applicable)

Address of Doctor/Personal Physician (if applicable)

Phone Number of Doctor/Personal Physician (if applicable)

Please Tick And Describe Any Health Conditions Which You Are Experiencing (Or Have Previously Experienced)




Please List All/Any Medications You Are Taking That Have Been Prescribed By Your GP

Please List Any Non-Prescription Medication You Are Taking

Within The Last 6-Months, Have You Taken Or Used Any Of The Following?


Steroid Cream
Blood Thinning Medications
Photosensitive Medications


In the Last 5-Years, Have You Ever Undergone Any Surgery Or Plastic Surgery?

If Yes, When?

What Information Can You Provide About the Procedure? (if applicable)

In the Last 12 -months, Have You Undergone Treatment From a Dermatologist
(ie – Skin Peel, Botox, Fillers, Laser, etc)

If Yes, When?

What Information Can You Provide About the Procedure? (if applicable)

Previous Treatments & Expectations

Have You Ever Previously Received Any Body Contouring Procedures? (Cavitation, Fat Freezing, Radio Frequency or HIFU for Face or Body)

If Yes, Were You Happy With The Results?

If No, Please Describe


Area(s) Of Concern

Which Area(s) Of The Body Are You Focused On/Concerned With

Please Describe The Specific Concern(s) Which Brought You In Today.

What Are Your Expectations Of Your Chosen Treatment With Elite Body Contouring? (ie – Reduce Fat, Tighten Skin, etc)

Client Release & Disclaimer

Pregnant, recently pregnant or breastfeeding women (or women who are actively trying to fall pregnant)
Patients with Cardiac Problems & Heart Conditions
Patients with Vascular Diseases
Patients with Coagulation Disorders (Haemophilus) Blood Clots
Patients with Pacemakers, Stents, or Any Implants to do with Heart Valves
Patients with Thrombosis and/or Thrombophlebitis
Patients Being Treated with Anticoagulants or Blood Thinners
Patients with Skin Thinning or Using Sun-Sensitive Medications
Patients Who Have Undergone a Medical Transplant
Patients who have Undergone a Recent Surgery (3-6 months post operation, or dependant on healing)
Patients with any Open Wounds
Patients with an infection or skin sensitivity to treatment areas
Pateints with Kidney Disease or Malfunctioning Kidneys
Patients with Cancer or History of Cancer
Carriers of Large Metal Prosthesis
Patients with a Tendency To Keloid Scar Tissue
Patients Using Regular Anti-Inflammatory Medication
Patients With a Hernia
Patients Who Have Epilepsy
Patients Who Are Diabetics
Patients With Autoimmune Conditions
Certain Medications (Please check with Therapist)
Patients with Implants or Screws On or Near Treatment Area
Patients who have had Facial Threads within 1-year


Possible Side-Effects
Possible side-effects of non-sirgical treatments can include: redness, bruising, skin sensitivity, numbness, swelling, discomfort, bliserting, Freeze burn (fat-freezinfg) or in rare cases, Paradoxical Adipose Hyperplasia (Where fat cells can harden and have to be surgically removed)


Reccomended Treatments & Results
The treatment plan and amount of treatments that have been reccomended during the consultation appointment should be followed to obtain the results that the individual seeks. Results may vary from person to person – individual client history, body composition and age are factors which may impact results. We do not guarantee results.

Whilst our treatments are devised to deliver results, they are best combined with a well maintained and healthy diet and lifestyle.

In order for us to deliver exceptional service and measure results we are required to conduct an InBody body composition scan, follow the reccomended treatment plan, take and record before and after photos of all clients, and record treatment notes, and the client must provide us with any requested information to assess any issues or concerns.

Should you not disclose required information or the permitting of tracking your results with scans and photos, this can impact the results and our ability to assist you. You acknoledge that the best results cannot be obtained with only one treatment and our reccomended treatment plan/course should be followed.

Results can take time and can be seen from as little as 4-6 weeks and gradually over the following 8-12 weeks post-treatment. Resultds will vary depending on which treatment is performed on the individual. It is important to follow our guidelines and pre/post care instructions and all other instructions as advised by the Therapist

Client Image Release Consent (Optional)

I give Elite Body Contouring Pty Ltd (ABN 23 607 798 872), its related entities, affiliates, assigns, successors, licensees, legal representatives, employees and agents (“EBC”) the irrevocable right to use my photograph/ image/audio recording/video recording and likeness in all forms and manner (“My Image”) for the purposes of advertising, media publicity, publication, training, general display, or for any other purposes in whole or in part, including but not limited to publication on internet web sites, broadcasts and any other publications as released to or by EBC (“Publication”) in alignment with the level of release authorisation selected below.

I waive any interest that I may have in the copyright to My Image now or at any future time and acknowledge that I am not entitled, nor shall in the future be entitled, to receive any payment or consideration in respect of it and agree to make no claim against EBC for any payments for the Publication of My Image. I understand EBC cannot control unauthorised use of My Image by persons not associated with EBC upon the Publication of My Image. I forever waive any right to inspect or approve any Publication of My Image by EBC. I release and indemnify EBC from any loss, damage, costs, expense, or claim (including consequential loss) connected with the Publication of My Image, including action for defamation, libelous material, breach of privacy, or copyright.


Select Relevant Level Of Release Authorisation Below:

Client Signature & Authorisation

I certify that the above statements and information I have provided are true and corrent and I have been advised by my Therapist, completely understand the implications of the treatment that I will be receiving, including the listed side-effects and at no time have I been misled or incorrectly informed by the therapist or company. Any falsifications of information submitted by me could be determental to my health and succesds of my treatment, and the company will not be held liable. I have been advised that I may experience possible discomfort during the treatment of Cryolipolysis and a temporary loss of sensation of the area treated. Non-refundable deposits and packages may not be transferred to any other individual. I hereby authorise and direct the Therapist to administer the prescribed process and perform such procedures as may be deemed necessary or advisable. My signature below constitutes my acknowldegment that:

1) I have read, understood, and fully agree to the foregoing and I have received and read the pre and post
care treatment information

2) I give consent to the proposed treatment process thar has been satisfactorily explained to me and I have
all the information that I desire

3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of any
claims that I have or may have in the future in connection with the desired treatment.

Please sign in the box and then click the “Agree & Sign” button below.
Please return tablet to the front desk once this has been completed.

Leave this empty:

Elite Body Contouring https://elitebodycontouring.com.au
Signature Certificate
Document name: Welcome to Elite Body Contouring - Rosebery
Unique Document ID: c055bb035eff3e60350725f2c26852a3056c13cf
Timestamp Audit
May 14, 2020 11:24 am AESTWelcome to Elite Body Contouring - Rosebery Uploaded by Danielle Smith - Danielle@elitebodycontouring.com.au IP
May 18, 2020 10:24 am AESTJagan Lamb - Jagan@elitebodycontouring.com.au added by Danielle Smith - Danielle@elitebodycontouring.com.au as a CC'd Recipient Ip:
May 18, 2020 10:24 am AESTDanielle Smith - Danielle@elitebodycontouring.com.au added by Danielle Smith - Danielle@elitebodycontouring.com.au as a CC'd Recipient Ip:
May 18, 2020 11:02 am AESTJagan Lamb - Jagan@elitebodycontouring.com.au added by Danielle Smith - Danielle@elitebodycontouring.com.au as a CC'd Recipient Ip:
May 18, 2020 11:02 am AESTDanielle Smith - Danielle@elitebodycontouring.com.au added by Danielle Smith - Danielle@elitebodycontouring.com.au as a CC'd Recipient Ip: