Lypossage Program Intake Form

Date

First Name

Last Name

Date of Birth

Phone

Address

City

State

Zip

Please describe any medical information items checked

Are you pregnant

Yes No

Have you had a professional massage before?

Yes No

Please list any medications or supplements you are taking

If you have ever had cosmetic surgery or liposuction, where and was the experience successful?

Please describe any position you may have difficulty lying in.

What are your Lypossage goals?

Please describe your areas of concern checked

Lypossage Program Conditions

To keep all of my lypossage appointments
To maintain (At Least) my normal eating habits
I consent to being photographed at the beginning and at the end of the series for the purpose of recording changes in the target areas
I consent to be measured at the beginning, the middle and at the end of the series, for the purpose of recording changes in the target areas
I will report any significant health issues that may occur during the lypossage body contouring program
I am aware that all files, photographs, and measurements are the property of Circle of Wellness
I give my permission for Circle of Wellness to publish statistical data and photographs derived from my lypossage body contouring program

I Agree to the conditions of my lypossage body contouring program as stated above:

Lypossage Program Consent to Treat

By clicking this box and entering my name in the signature field below, I understand that lypossage is not a massage treatment as much as it is a “body Contouring method” of body work. I am aware that in practicing this method no attempt is made to diagnose illness or disease or any other disorder and that the practitioner doing the lypossage body contouring method will not prescribe or preform spinal manipulations as part of the lypossage body contouring treatment. It is further understood that I will keep my doctor and the lypoassage practitioner aware of any and all physical or mental changes during the lyopassage program period. I have stated all my known medical conditions. I am also aware that my body worker is a certified lypossage practitioner.

Patient Name (signature)

Lypossage Program Intake Form – Rockford, IL