Non-surgical Body Contouring – BodyRejuvenation

Health and Lifestyle

Do you have any known allergies?

Yes
No

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Do you have any medical conditions or are you currently taking any medications?

Yes
No

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How would you describe your overall health?

Excellent
Good
Fair
Poor

Goals and Expectations

Which area(s) are you interested in treating?

Select all that apply

Please specify

What are your primary goals for non-surgical body contouring?

Select all that apply

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What concerns do you have regarding non-surgical body contouring?

Select all that apply

Please specify

Treatment Specific Questions

Have you previously undergone any non-surgical or surgical body contouring treatments?

Yes
No

Please specify

How often do you exercise?

Daily
A few times a week
Rarely
Never

Which treatment(s) are you most interested in?

Lipolysis Injections (e.g., Kybella)
EvolveX by Inmode (Radiofrequency lipolysis with electro muscle stimulation)
Butt Lift with Radiesse Filler

What is your preferred timeframe for starting the treatment?

As soon as possible
Within the next month
Within the next 3 months
Within the next 6 months

Additional Information

Are you interested in a consultation to discuss your options in detail?

Yes
No

Do you have any other comments or questions?

Are you interested in proactive healthcare and preventative measures to optimize your health and longevity?

Yes
No

Do you stay active and prioritize healthy lifestyle habits like exercise and nutrition?

Yes
No

Would you be open to exploring evidence-based, cutting-edge therapies for anti-aging and wellness?

Yes
No

Are you comfortable providing recent blood work or participating in a comprehensive health assessment?

Yes
No

Do you believe in a collaborative approach to healthcare, working with medical professionals to achieve your goals?

Yes
No

How much do you budget for beauty and wellness each year?

Less than $1000
More than $1000. Less than $10,000
More than $10,000

In the last 3–6 months, what’s been the most frustrating part about your health, energy, or appearance? Please be as specific as possible

(numbers on the scale, lab results, clothes that don’t fit, comments from others, photos you didn’t like, etc.).

Can you describe a recent moment when this problem really bothered you or got in the way of your life? What happened, and how did it make you feel?

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Name

First

Last

Email

Phone

How did you hear about us?

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Our clinic is located in Hallandale, Florida, are you nearby?

Yes
I can make it
No, but I'm OK with a virtual consultation

If you live far, we do offer virtual consultations