Medical Questionnaire

Please fill out the following form to help us understand your physical condition- For Fat Freezing /Emvibe Treatments

First Name

Email Address

Last Name

Date of Birth

PLEASE TICK IF YOU HAVE ANY OF THE FOLLOWING OR IF IT APPLIES TO YOU: --- High Blood Pressure / Diabetes / Heart Issues / Pregnant / Skin Sensitivity to cold temperatures / Do you have any skin conditions sensitivity that may affect you from doing a treatment / Abdominal Hernias / Cryoglobulinemia cold agglutinin disease /paroxysmal cold hemoglobinuria

Yes

Are you currently suffering from a medical condition, illness, or injury?

Yes

If you answered yes to any question, please elaborate / Add Mobile Phone Number here

Initials

Today's Date

I declare the info I’ve provided is accurate & complete & ( I am fully Covid Vaccinated )

Thanks for submitting!

VIBRATION CAFE

FAT FREEZING SPECIALISTS

360 DEGREE FAT FREEZING / EMVIBE SLIM / PRO VIBRATION MACHINES

0478 742 596

Medical Questionnaire