Client Intake Form

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Personal Information - Step 1 of 4

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Number

Work Number Number

Cellphone *

Email *

Height *

Weight *

Age *

Gender *

Are you currently under the care of a physician? *

Do you exercise? *

How often? *

What type of exercise? *

Do you have heart concerns? *

Name energy? What

Describe your heart concerns *

Are you going through active Cancer Treatment? *

Date of your last treatment *

Do you have any skin condition? Which skin condition? *

Do you have any electronic or metal implants? *

Please give us more information *

Do you have any allergies? Which allergies? *

Are you diabetic? *

How much weight have you decided to lose *

What methods failed to help you lose weight? *

How many times a year do you diet? *

Is successful weight loss a top priority (explain)? *

What new activities will you become involved in after losing weight? *

How fast do you want to be thin, trim, and fit? *

Do you feel tired, run down, and out of energy? *

Please describe the areas of your body that you want to change *

Why did you choose Contour Light®? *

What do you expect from your red light treatment? *

If you were referred by one of ourclients, please tell us who so we can send a Thank You note

CANCELLATION POLICY *

The client agrees to give a minimum of 48-hours notice to cancel a scheduled session or will pay 50% of the treatment fee.

48 hours or more: There is no charge.
Less than 48 hours.
No Show: The client will be charged 100% of the session price.

CANCELLATION POLICY *

I have read and agree to the terms of the cancellation policy

PERSONAL DISCLOSURE *

I have stated all my known medical conditions, answered all questions honestly and will inform the practitioner of any relevant change in my health. I agree to waive all claims and to release and hold harmless Shiwa Therapy Technicians from any liability whatsoever. I understand this treatment is cosmetic in nature. Furthermore, I have discussed any questions I may have regarding studio policies, client rights and Florida law as stated herein and have received satisfactory answers.

Checkboxes *

I consent to receiving SMS text messages for appointment confirmation purposes.

Client Intake Form

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