endermologie intake form

Endermologie Intake Form

Please fill out the information below.

Endermologie Intake Form

Gender
Are you currently under a physician's care for any reason?
If we have questions related to your treatment(s) do we have permission to contact your physician and discuss your health records?

Please indicate your daily consumption of the following: (place a number value that represents the average daily intake)

Do you exercise?
Please check the box next to any of the items below that you currently have or have had a history of:
Are you pregnant or planning a pregnancy in the next 3 months?
Are you using hormonal contraception?
Are you undergoing hormone replacement therapy (HRT)?
Are you perimenopausal or menopausal?
These questions specifically apply to the face. Please check the box next to any of the items below that you currently have or have a history of:
In the last six months have you had:

Thanks for submitting!