Achieve Your Weight Loss Goals with RENEW Med Spa in Springfield, MA

Name:

Phone:

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🩺 Medical History (Check All That Apply)

Liver Condition

Skin Disease

High Blood Pressure

Thyroid Condition

Auto Immune Disease

Cancer (past 12 months)

Diabetes

Epilepsy

History of Gallstones

Metal implants or bone pins

Cardiovascular condition

History of blood clots, phlebitis, or thrombosis

Have you had any past surgeries?

Yes

No

If yes, list procedures and dates

Do you take prescription medications?

Yes

No

If you do, please list them below

How much water do you drink daily?

1-2 Bottles

3-4 Bottles

5-6 Bottles

7+ Bottles

Do you follow a diet plan?

Yes

No

If so please explain

Do you exercise regularly?

Yes

No

If yes, what type and how often?

When is your next menstrual cycle? (Note: Avoid certain treatments during your cycle as it may cause heavier bleeding.

📜 Consent Agreement: By typing my name below, I confirm that I have provided truthful and complete answers to the best of my knowledge. I understand that it is my responsibility to inform my technician of any changes in my health. I voluntarily consent to receive body sculpting treatments and release Renew Med & Spa from any liability related to this procedure.

Body Sculpting Medical Intake

CONTACT INFORMATION

BUSINESS HOURS