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Body Fat (If known, include method and date measured)
If there a specific coach you would prefer to work with, please select their name below:
I Don't Know
Would you like V3 Aesthetics to assign you a coach?
Would you like a consultation with one of our coaches?
Please send current pictures of yourself to email@example.com if you would like to discuss your options based on your current physique, please provide at least 2 FULL BODY images.
Health & Medical History:
Please elaborate on any checked boxes above, or add additional relevant information not included on the list.
Are you pregnant or nursing?
Please list any and all medications, supplements, vitamins, etc., that you are currently taking (enter in space below).
Do you have a history of metabolic disease/disorder? Please include any thyroid issues.
Do you smoke (yes/no)? If yes, how many per day, and for how long (months/years)?
Do you drink alcoholic beverages? If yes, how many drinks per day / and what type of alcohol?
Do you have any food allergies? If yes, please list.
Please list any and all medical/health conditions and mobility/activity restrictions not listed above. If not applicable, enter NONE.
Do you have a MyFitnessPal Account?
If yes, what is your MyFitnessPal username?
If yes, what is your MyFitnessPal password?
If no, would you like us to create a MyFitnessPal account for you?
Nutrition & Exercise
In the spaces below, please provide an overview of your current nutrition and exercise regimen. Please answer these questions honestly so that we may create a plan that is based on factual data. Your results well be a direct reflection of the accurate snapshot that you provide.
Please provide an accurate description/overview of your current daily meal plan.
Are you following a specific nutrition plan?
How many meals do you eat per day?
How many calories do you consumer per day?
Please provide a list of all the meals, snacks and beverages that you consume in a day. Try to provide the time of each meal/snack and each serving size to the best of your ability.
Please provide an overview of a week of training. Include in your description the duration of activity and specific types of training (cardio, strength training, yoga, etc.), targeted body part(s), frequency, etc.
Please read the following carefully. By submitting your electronic signature at the end of this section, you agree to any and all terms and conditions as outlined in this document. With exception of the Model Release, acceptance of all terms and conditions is required to participate in any program offered by V3 Aesthetics LLC.
GENERAL RELEASE - I agree to allow V3 Aesthetics LLC to design a program for me to use as part of my competition preparation. I will not hold V3 Aesthetics LLC and/or any related persons or parties personally liable for injuries, illnesses or problems that might occur as a result of the program developed for me. This program does not replace the expert advice or medical treatment of a healthcare or medical professional. I affirm that I have provided V3 Aesthetics LLC with all necessary and pertinent information. I take full responsibility for any and all complications, injuries, illnesses or death that may occur as a result of this program. (If you accept, type initials below)
MODEL RELEASE - Whereas for valuable consideration hereby acknowledged as received, the Model granted V3 Aesthetics LLC permission to photograph him/her and thereafter to use the photographs in whole or in part without restriction anywhere, in any medium, for any purpose and altered in any way. The Model releases V3 Aesthetics from all claims of liability relating to the use of the photographs. This permission and release shall be irrevocable and binding upon the Model's successors, legal representatives and assigns and shall accrue to the benefit of V3 Aesthetics LLC's successors, legal representatives and assigns. (If you accept, type your initials below)
REFUND POLICY - By typing your initials below you acknowledge that there is no refund in whole or in part of the initiation fee once paid. (If you accept, type your initials below)
CANCELLATION POLICY - We require a 30 day cancellation notice should you decide to quit services with V3 Aesthetics, LLC. you must submit your cancellation to our email address firstname.lastname@example.org. If your billing date falls within the 30 day period we will prorate your fees accordingly. (If you accept, type initials below)
RELEASE AND HOLD HARMLESS AGREEMENT - I understand that my participation and/or involvement in V3 Aesthetics, LLC carries with it the potential for certain risks, some of which may not be reasonably foreseeable. I further acknowledge that these risks could cause me, or others around me, harm, including, but not limited to, bodily injury, damage to property, emotional distress, or death. I am a willing participant in any and all V3 Aesthetics LLC activities, events, programs. By signing this agreement, I agree to release, indemnify, and hold harmless V3 Aesthetics LLC, as well as all its employees, agents, representatives, successors, etc. from all losses, claims, theft, demands, liabilities, causes of action, or expenses, known or unknown, arising out of my participation in any and all V3 Aesthetics LLC activities, events, programs. (If you accept, type your name as you would sign it below. This is to be considered your E-SIGNATURE)