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Bayside Endermologie Client Intake Formyews-admin2026-06-15T15:41:17+10:00

Bayside Endermologie Client Intake Form

Bayside Endermologie Client Intake Form

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CLIENT INFORMATION

Gender(Required)

Male

Female

Other

Name(Required)

Date of Birth(Required)

Phone(Required)

Email(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

Would you like to receive email promotions and updates?(Required)

Yes

No

How did you hear about us?

Personal referral

Facebook/Instagram

Website/Online Search

YouTube

Yelp

Twitter

Online Advertisement

Newspaper/Magazine

If referred, please provide their name:

SERVICES OF INTEREST

Ultraformer MPT

LPG Endermologie

TeslaFormer

TeslaChair

Cold Plasma

Fibroblast Plasma

Enzyme Peels

Infrared Sauna

MEDICAL HISTORY

Do you have any known reactions to chemicals, cosmetics, or skincare products?(Required)

Yes

No

If yes, please describe

Do you have any allergies?(Required)

Yes

No

If yes, please list:

Do you have any medical conditions that may affect your treatment?(Required)

Yes

No

If yes, please specify

Are you currently taking any medications?(Required)

Yes

No

If yes, please list

CONSENT & AGREEMENT(Required)

I acknowledge that the treatments provided by Bayside Endermologie are for wellness and cosmetic purposes. I have disclosed all necessary medical conditions and allergies. I understand the risks associated with treatments and agree to follow all post-treatment care instructions. I consent to treatment and understand that results may vary.

Date(Required)

Client Signature(Required)

Disclaimer: Thank you for choosing Bayside Endermologie. This form is used to collect information about new clients and is for internal use only. All information provided is confidential and will be treated accordingly.

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Contact Info

Level 1/42 East Concourse, Beaumaris, Vic 3193
Phone: 0448 892 914
Contact Us Now
Open by Appointment

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TESLAChair
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Ultraformer MPT
Fibroblast Plasma Skin Tightening Melbourne | Bayside Endermologie
Cold Plasma
Infra-Red Sauna

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