Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Date / Time *DateTimeLocation *SpringfieldWoodbridgeServices *Name/Nombre *FirstLastPhone *Email *Address/Direccion *How did you her about Curvilinea?/ Como escuchaste de Curvilinea? *InstagramA FriendGoogleFacebookWebsiteSupportOtherHave you ever gotten body wrap?/ Alguna vez se ha hecho Body Wrap *YesNoHeight/Altura *Weight/Peso *Are you now under a doctor's care?/ Estas bajo el cuidado de un doctor? *YesNoIf yes explain the reason/ Si es Si explique porque motivoPlease give your doctors information/ Por favor de la informacion del doctorAre you currently taking any medication?/ Estas tomando algun medicamento? *YesNoIf yes,what for?/ Si es Si, porque motivo?Do you have any circulatory or respiratory problems?/ Tiene problemas del corazón o respiratorios? *YesNoIf yes,what for?/ Si es Si, porque motivo? Allergies/ Alergias *Do you have skin disease?/ Tiene alguna. enfermedad en la piel? *Do you have high or low blood pressure?/ Tiene problemas de presion? *Do you have any heart ailment?/ Tiene alguna enfermedad del corazón? *Do you have diabetes?/ Tienes diabetes? *YesNoHave you had any surgery? Explain/ Ha tenido cirugías? Explique *Are you pregnant?/ Esta embarazada? *YesNoAre you on any diet?/ Esta haciendo alguna dieta? *YesNoIf yes, explain/ Si es Si, explique *Any other medical condition?/ Algun lotro problema de salud? *Notes/ Notas * *I understand that I am wrapped at my own risk and management of this establshment and its employees assume no liability of any kind. I have read and understand the brochure provided by this company, and I agree the all statements contained therein are made in good farth by this company, and i hereby release this company for any negligent misrepresentations that may be contained in said brochure. I understand the procedure which will be performed on me, and all of my questions and concerns have been addressed.Signature *Submit
