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THE PERFECT FRAME
By Tia Renee
THE PERFECT FRAME
By Tia Renee
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HOME
ABOUT ME
GALLERY
BEFORE AND AFTER
PRODUCTS AND APPAREAL
PAYMENT PLANS
BOOK SERVICES ONLINE
AFTER CARE
FAT DISSOLVE AFTER CARE
CONTACT
TERMS AND CONDITIONS
PLANS & PRICING
**Please fill out Both forms below before your visit. **
Consultation Form
First Name
Last Name
Email
Code
Phone
1. Do you have uncontrolled high blood pressre?
2. Do you have a thyroid problem?
3. Do you have any allergies?
3A. If so, what are they?
4. Do you suffer from cognitive heart failure?
5. Do you have Epilepsy/ Seizures?
6. Are you pregnant or trying to be pregnant?
7. Do you suffer from Parkinsons or Multiple Sclerosis?
8. Have you had a recent joint injury?
10. Do you have a recent wound from an operation/surgery?
9. Do yo have a Pacemaker or Defibirillator?
11. Are you under 16 or over 65?
12. Do you have a metal rod, artificial joint, or any surgical implants?
12A. If so, what are they?
13. Do you have issues with blood clots?
14. Are you taking blood thinners?
15. Do you have a hard time breaking a sweat?
16. Are you taking blood thinners?
17. Do you have any skin diseases or conditions?
17A. If so, what are they?
18. Have you had this procedure before? If no, please skip to question 20.
What cosmetic procedure did you have performed?
19. If so, were you happy with your services?
19A. Why or why not? What was the date of your surgery?
19B. What cosmetic procedure did you have done?
19C. What is your doctor's name?
20. Do you bruise easily?
21. Are you a diabetic?
22. Are you breast feeding?
23. Are you undergoing any hormone replacement therapy?
24. Do you have cancer or is undergoing chemotherapy or radiation?
25. Are you currently on your menstrual cycle?
26. Do you have any dental implants?
Submit
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Perfect Frame LLC
Media Consent Form
First Name
Last Name
Email
Date of Birth
Initials
I hearby authorize The Perfect Frame Spa to (Check all that apply)
Photograph me
Video me
Record me
None of the above
Submit
Thanks for submitting!
HOME
ABOUT ME
GALLERY
BEFORE AND AFTER
PRODUCTS AND APPAREAL
PAYMENT PLANS
BOOK SERVICES ONLINE
AFTER CARE
FAT DISSOLVE AFTER CARE
CONTACT
TERMS AND CONDITIONS
PLANS & PRICING
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