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- Cellulite
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For Men
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Home
About Us
Treatments
For Women
- Arms
- Cellulite
- Chin and Face
- Hips and back
- Legs
- Neck
- Stomach
- Waist and Buttocks
For Men
Promotions
Contact

Home
About Us
Treatments
For Women
- Arms
- Cellulite
- Chin and Face
- Hips and back
- Legs
- Neck
- Stomach
- Waist and Buttocks
For Men
Promotions
Contact

Home
About Us
Treatments
For Women
- Arms
- Cellulite
- Chin and Face
- Hips and back
- Legs
- Neck
- Stomach
- Waist and Buttocks
For Men
Promotions
Contact

Book a Consultation

Customer Data Pre Appointment Northampton

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If you were directed to this page, it’s because one of our consultants has already spoken with you and scheduled your appointment.

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Once we receive it, we will be in touch if we have any questions.

Fill Out the Form Northampton

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Client Name*
Date of Birth*
Gender*
- Male
- Female
Occupation*
Practitioner Name*
Post Code*
Telephone No*
Your Email*
Todays Date*
Address*
Health and Lifestyle
Contraindications
Liver/Kidney Disease*
- Yes
- No
Heart Conditions inc. Pacemaker*
- yes
- No
Silicosis or other Lung Conditions*
- yes
- No
Cancer (Radiotherapy/Chemotherapy)*
- Yes
- No
Reynaud’s Disease (or other vaso constrictive disorders)*
- Yes
- No
Physical Hypotonic*
- Yes
- No
Cardiovascular Disease*
- Yes
- No
Cerebral Disease*
- Yes
- No
Immune System Disease (i.e. AIDS or HIV)*
- Yes
- No
Immune System Disease (i.e. AIDS or HIV)*
- Yes
- No
Urticarial or other immune disorders*
- Yes
- No
Hypoproteinaemia*
- Yes
- No
Frostbite Intolerance*
- Yes
- No
Hernia or weak stomach muscle walls*
- Yes
- No
Severe diabetes*
- Yes
- No
Recent invasive surgery (in the last 12 months)*
- Yes
- No
Artificial Implants (bone, etc)*
- Yes
- No
Metal Plates or Joint Implants*
- Yes
- No
Sites of prior cosmetic surgery*
- Yes
- No
Pregnant or Breastfeeding*
- Yes
- No
Currently under the influence of drugs or alcohol*
- Yes
- No
Do you have any of the following?
Hyper or Hypotension*
- Yes
- No
Scarring history, fibrosis or seborrhoea*
- Yes
- No
Haemophilia or other clotting disorders*
- Yes
- No
Epilepsy*
- Yes
- No
Diabetes*
- Yes
- No
Thyroid Condition*
- Yes
- No
Hormonal Imbalances*
- Yes
- No
Other immune disorders not listed*
- Yes
- No
Received or donated organ transplants*
- Yes
- No
Psoriasis or eczema in treatment area*
- Yes
- No
Keloid/hypertrophic scar in the region*
- Yes
- No
High Cholesterol*
- Yes
- No
Thrombosis (past or present)*
- Yes
- No
Broken Bones*
- Yes
- No
Undiagnosed swelling or inflammation*
- Yes
- No
Bruising, cuts or abrasions (treatment area)*
- Yes
- No
Fever*
- Yes
- No
Menstruation*
- Yes
- No
Any other conditions not listed*
- Yes
- No
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If you have answered yes to any of the above, please give full details:*
Are you currently taking any medication?*
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Do you exercise?*
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How is your sleep pattern?*
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How is your diet?*
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Do you drink alcohol?*
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Do you smoke?*
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If yes, please list all medications*
No. of Hours Sleep per night:*
How much water do you drink per day?*
If yes, how many units per week?*
If yes, how many cigarettes per day?*
How often do you exercise per week?*
Have you ever had cryo body contouring or any fat removal or similar treatments before? If yes, please give details below including the type of treatment and the area.*
- Yes
- No
Are you fully committed to making the relevant changes to get the best possible results from your treatment? YES NO*
- Yes
- No
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TREATMENTS OFFERED

Cryolipolysis Fat Freezing
HIFU Non Surgical Facelift
Aqualyx Fat Dissolving Injections
Collagen Lift Therapy
Ultimate Lift & Tighten Treatment
LA-EMS Body Sculpting
Cryopen Blemish Removal
Femiwand Vaginal Rejuvenation
LA-EMS Incontinence Treatment

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LA LIPO

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Treatments

Cryolipolysis Fat Freezing
HIFU Non Surgical Facelift
Aqualyx Fat Dissolving Injections
Collagen Lift Therapy
Ultimate Lift & Tighten Treatment
LA-EMS Body Sculpting
Cryopen Blemish Removal
FemiWand Intimate Wellbeing
LA-EMS Pelvic Floor Information

Information

About Us At LA LIPO
Prices
Erectile Dysfunction Information
Faecal Incontinence Information
What We Do
Join Our Team

Contact Us

03300100238
Request Call Back
Sitemap

Book a Consultation

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All treatments are non-surgical aesthetic procedures. Suitability is assessed at consultation and results can vary between individuals.

ENGLAND Northamptonshire

Brackley
Corby
Daventry
Deanshanger
Earls Barton
Farthingstone
Higham Ferrers
Northampton
Wellingborough

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