Welcome to Elite Body Contouring - Form
Thank you for booking with Elite Body Contouring – Form. 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
Date of Birth:
Which Industry Do You Work In?
Select…Agriculture & Natural ResourcesBuilding & ConstructionBusiness Administration & ManagementEducation & TrainingBanking & FinanceGovernment & Public AdministrationHealth & Medical ScienceHospitality & TourismInformation Technology (IT)Law, Public Safety, or SecurityManufacturing & ProductionMarketing, Sales, PR or AdvertisingRetail & Consumer GoodsScience, Technology or EngineeringTransportation, Logistics & DistributionOther or Not Applicable
On Average, How Many Hours of Sleep Do You Have Each Night?
Select…2-6 Hours6-8 Hours8+ Hours
On Average, How Often Do You Exercise Per Week?
Select…No Regular Exercise1-3 Days Per Week4-5 Days Per Week6-7 Days Per Week
On a Scale from 1 (low) to 10 (high), How Would You Rate Your Stress Levels?
Select…1 – 10Not ApplicableLess than 6 Months Old6-12 Months Old1-2 Years Old2-5 Years Old5+ Years Old
If You Have Children, How Old Is Your Youngest Child?
Select…Not ApplicableLess than 6 Months Old6-12 Months Old1-2 Years Old2-5 Years Old5+ Years Old
Describe In Detail (Including Product Names) Your Current Home Skin Care Regime
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?
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)
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
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)
ContraindicationsPregnant, recently pregnant or breastfeeding women (or women who are actively trying to fall pregnant)Patients with Cardiac Problems & Heart ConditionsPatients with Vascular DiseasesPatients with Coagulation Disorders (Haemophilus) Blood ClotsPatients with Pacemakers, Stents, or Any Implants to do with Heart ValvesPatients with Thrombosis and/or ThrombophlebitisPatients Being Treated with Anticoagulants or Blood ThinnersPatients with Skin Thinning or Using Sun-Sensitive MedicationsPatients Who Have Undergone a Medical TransplantPatients who have Undergone a Recent Surgery (3-6 months post operation, or dependant on healing)Patients with any Open WoundsPatients with an infection or skin sensitivity to treatment areasPateints with Kidney Disease or Malfunctioning KidneysPatients with Cancer or History of CancerCarriers of Large Metal ProsthesisPatients with a Tendency To Keloid Scar TissuePatients Using Regular Anti-Inflammatory MedicationPatients With a HerniaPatients Who Have EpilepsyPatients Who Are DiabeticsPatients With Autoimmune ConditionsCertain Medications (Please check with Therapist)Patients with Implants or Screws On or Near Treatment AreaPatients who have had Facial Threads within 1-year
Possible Side-EffectsPossible 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 & ResultsThe 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
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.
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 postcare treatment information
2) I give consent to the proposed treatment process thar has been satisfactorily explained to me and I haveall the information that I desire
3) I hereby give my consent and authorisation voluntarily and release the establishment and its agents of anyclaims 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.
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Document Name: Welcome to Elite Body Contouring - Form
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