CLIENT INTAKE FORM
Full Name
Address
Phone
Email
Date of Birth
Click the year on calendar to start
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CLIENT INTAKE FORM
Do you smoke ?
Yes
No
Yes
Do you consume alcohol ?
Yes
No
Yes
Do you exercise regularly ?
Yes
No
Yes
Are you currently taking any medications ?
Please list all medications (including over the counter)
Do you have any allergies ?
Please list any known allergies
Do you have any issues and/or past experiences with bruising or bleeding ?
Yes
No
Yes
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CLIENT INTAKE FORM
Your Medical History | Please check those that apply to your history.
Pregnant
Lactating
Hernia(s)
Abdominal Surgeries (CSection)
Open and/or infected wounds (including tattoos)
Sensitivity to hold/cold temperatures
Use of blood thinners
Allergies to latex
Severe skin diseases
Raynaud's Disease
History of Cancer
If applicable, how long have you had these concerns? Have you received treatment?
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CLIENT INTAKE FORM
Please provide information about your upcoming/current visit and treatment
Date of Surgery
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What procedure did you receive or plan to receive ?
Surgeon / Clinic
Please rate your discomfort ( 5 being extremely uncomfortable and sore)
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Level of Discomfort
Referred by
Permission to use images taken of you (no face) to showcase before and after results on our website and social media ?
Yes
No
Yes
I confirm that, to the best of my knowledge, the answers above are correct, and I have not withheld any relevant information. I hereby agree to assume all risk and responsibility and to hold Opulor Body & Wellness Spa and its employees harmless in the event I sustain any injury, burn, or damage to my person, directly or indirectly, as a result of my receiving services. I understand that Opulor Body & Wellness Spa services and treatments are not a substitute for medical attention or examination. I furthermore agree to release Opulor Body & Wellness Spa and its employee from any claim, cause of action, suit, damages, etc. that may result from any such injury or damage.
I confirm and agree
Print Name
Signature
Clear
Date
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COVID -19 Release
Please sign below for complete release and understanding of the COVID-19 release risk informed consent
I have read and understand all the potential risks , including but not limited to the potential short-term and long term complications related to COVID-19 , and I would like to proceed with my desired treatment(s). I recognize that all the staff and owners at Opulor Body & Wellness Spa are closely monitoring this situation and have put in place reasonable preventive measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment, and I give my express permission for Opulor Body & Wellness Spa to proceed with the same.<br><br>I understand the explanation and have no more questions and consent to the treatment(s). <br><br>I have read Opulor's COVID-19 Informed Consent and release Opulor Body & Wellness Spa, Opulor's staff/contractors, and owners of all liability related to COVID-19.
Signature for COVID- 19 Release
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Today's Date
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