Treatment Consultation FormPatient Name: Date:

Gender: Weight: Age: BMI:

What are the patient’s areas of concern?

How did he/she hear about SculpSure?

Has your patient tried other fat reduction methods? If yes, please list:

Is your patient preparing for any special events?

Notes:

921-7026-015R1FOR OFFICE USE ONLY

Front

Treatment Plan

Back

Treatment Price: Discount: Total:

Treatment 1:Treatment 2:Treatment 3: