CLIENT HEALTH SCREENING FORM

Name

Address

Post code

State

Email

Phone

Medical History

Please tick all that apply to you:

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I am currently pregnant or breastfeeding

I have a pacemaker or implanted electronic device

I have metal implants (plates, screws, surgical mesh) in or near the treatment area

I have epilepsy or a seizure disorder

I have heart disease, heart rhythm issues, or severe cardiovascular conditions

I have active cancer or am currently undergoing cancer treatment

I have blood clots, thrombosis, embolism, or clotting disorders

I have severe liver or kidney disease

I have an autoimmune disease

I have a neurological condition

I have an active infection, fever, or systemic illness

I have open wounds, rashes, eczema, dermatitis, or broken skin in the treatment area

I have had recent surgery in the treatment area (within the last 3–6 months)

I have severe varicose veins in the treatment area

None of the above apply

Client Declaration

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I confirm that the information provided above is true and complete. I understand that failing to disclose medical conditions may affect my safety and treatment outcome. I agree to inform the practitioner of any changes to my health prior to treatment.

What goals do you have for your body, and how fast are you looking to achieve them?

I have completed this form to the best of my ability and knowledge, and agree to inform my therapist of any changes to the information listed on all pages of this health screening form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I agree to waive all liabilities toward my therapist and Refine Body Clinic for any injury or damages incurred due to any misrepresentation of my health history.

By signing below, I verify that I have read and understand the above statements and agree to them.

Client Name

Date

Signature