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Dr. Alex Alonso
Samantha Fonte
Mohammed Bilal Sheikh
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Aesthetic Intake Questionary
Endolift Treatment Form
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Personal Information
First Name
Last Name
Phone Number
Email Address
Date of Birth
Treatment Interest
Which treatment are you applying to model for?
Endolift
Skin Tightening
Body Contouring
Looking Tired
Other
Target Area (select one):
Lower Abdomen
Arms
Inner Thighs
Face & Neck
Undereyes
Jaw
Other
Eligibility & Goals
What is your primary goal?
Skin Tightenings
Fat Reduction
Both
Have you had any previous treatments in this area? (e.g., Lipo, Morpheus8, CoolSculpting, RF, PRP — please include approximate dates)
Are you currently pregnant, breastfeeding, or trying to conceive?
Yes
No
Do you have any active skin conditions, medical conditions, or implanted devices in the treatment area?
Choose Option..
Yes
No
If yes, please explain
Are you currently taking any medications or supplements that may affect healing?
Choose Option..
Yes
No
If yes, please specify
Availability & Commitment
Are you able to attend required follow-up visits at 4 and 12 weeks?
Yes
No
Are you available for your treatment and follow-ups during clinic hours?
Yes
No
Agreements & Consent
Commitment Agreement:
I understand this is a model opportunity and agree to attend all required follow-up appointments.
Selection Agreement:
I understand that submitting this application does not guarantee selection and that all models are chosen based on clinical suitability.
Media Release:
If selected, I consent to the use of my photos and/or videos for marketing, educational, and promotional purposes for Nuceria Health.
Signatures & Photo Submission
Signature
Sign here
Clear Signature
Save Signature
Please provide 2–3 photos of target area to evaluate:
Click to upload photos
Max 10 files (JPG, PNG)
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