hbspt.forms.create({ portalId: "6347683", formId: "6032bec1-13ce-4034-8d57-a3e6df530d02" }); Customer Data form Pre Appointment. Client Name* Date of Birth* DD dash MM dash YYYY Gender* Male Female Occupation* Practitioner Name* Post Code* Telephone No*Your Email* Todays Date* DD dash MM dash YYYY Address*Health and LifestyleContraindicationsLiver/Kidney Disease* Yes No Heart Conditions inc. Pacemaker* yes No Silicosis or other Lung Conditions* yes No Cancer (Radiotherapy/Chemotherapy)* Yes No Reynaud’s Disease (or other vaso constrictive disorders)* Yes No Physical Hypotonic* Yes No Cardiovascular Disease* Yes No Cerebral Disease* Yes No Immune System Disease (i.e. AIDS or HIV)* Yes No Immune System Disease (i.e. AIDS or HIV)* Yes No Urticarial or other immune disorders* Yes No Hypoproteinaemia* Yes No Frostbite Intolerance* Yes No Hernia or weak stomach muscle walls* Yes No Severe diabetes* Yes No Recent invasive surgery (in the last 12 months)* Yes No Artificial Implants (bone, etc)* Yes No Metal Plates or Joint Implants* Yes No Sites of prior cosmetic surgery* Yes No Pregnant or Breastfeeding* Yes No Currently under the influence of drugs or alcohol* Yes No Do you have any of the following?Hyper or Hypotension* Yes No Scarring history, fibrosis or seborrhoea* Yes No Haemophilia or other clotting disorders* Yes No Epilepsy* Yes No Diabetes* Yes No Thyroid Condition* Yes No Hormonal Imbalances* Yes No Other immune disorders not listed* Yes No Received or donated organ transplants* Yes No Psoriasis or eczema in treatment area* Yes No Keloid/hypertrophic scar in the region* Yes No High Cholesterol* Yes No Thrombosis (past or present)* Yes No Broken Bones* Yes No Undiagnosed swelling or inflammation* Yes No Bruising, cuts or abrasions (treatment area)* Yes No Fever* Yes No Menstruation* Yes No Any other conditions not listed* Yes No If yes please list:*If you have answered yes to any of the above, please give full details:*Are you currently taking any medication?* Yes No Do you exercise?* Yes No How is your sleep pattern?* Good Average Poor How is your diet?* Good Average Poor Do you drink alcohol?* Yes No Do you smoke?* Yes No If yes, please list all medications*No. of Hours Sleep per night:* How much water do you drink per day?* If yes, how many units per week?* If yes, how many cigarettes per day?* How often do you exercise per week?* Have you ever had cryo body contouring or any fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.* Yes No Are you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO* Yes No By pressing submit, you agree that we can contact you via the supplied details. We promise to only use your details to contact you in relation to this specific enquiry. Our full Privacy PolicyCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
