DATE:_____________________

NAME:___________________________________________ BIRTHDAY:____________ AGE:___________

MOBILE1PHONE:_____________________ HOME1PHONE:______________________
ADDRESS:______________________________________________________________
CITY:____________________________________________ STATE:_______________ ZIP:____________
EMAIL:1__________________________________________
HOW1DID1YOU1HEAR1ABOUT1US?___________________________________________

MEDICAL1HISTORY:
ALLERGIES:_____________________________________________________________
SKIN1TYPE:__________________________
CURRENT1ILLNESSES/CONDITIONS: CHECK1BOX1IF1YES
EPILEPSY
SKIN1INFECTION LOCATION?___________________________
SKIN1DISEASE TYPE:_______________________________
DIABETES
PREGNANT
CANCER
LUPUS,1MS,1RHEUMATOID1ARTHRITIS
THYROID1LOW1OR1HIGH
LIVER1DISEASE
PSYCHIARIC1PROBLEMS1EG.1DEPRESSION
METAL1IMPLANTS?
HIV
MENOPAUSE
HORMONE1REPLACEMENT WHAT1TYPE?__________________________
BARIATRIC1SURGERY
GLUTEN1INTOLERANCE
COLD1SORES
HERPES1TYPE1II
OTHER WHAT?_______________________________

LIFESTYLE
ALCOHOL1USE:1#alcoholic1drinks/day:__________________ #alcoholic1drinks/week:__________________
TYPE1OF1ALCOHOLIC1BEVERAGE:______________________
I1AM1A1RECOVERING1ALCOHOLIC
DO1YOU1SMOKE?:_________ HOW1MANY1PACKS/DAY?___________
DO1YOU1USE1THC1(Marijuana)1IN1ANY1FORM?____________
NAME:___________________________________________ DATE:___________
DIET
DIET:___________________________________________________________________________
TYPE1OF1DIET:_______________________ DO1YOU1EAT1IN1A1HURRY?1
#1MEALS1PER1DAY:________ #181oz1GLASSES1OF1Water/Day:_________

EXERCISE
I1EXERCISE DAILY1111111 TIMES1PER1WEEK:_______
I1DON'T1EXERCISE
MY1FAVORITE1EXERCISE1IS:
I1EXERCISE1WITH1A1FRIEND
I1EXERCISE1WITH1A1TRAINER
I1ENJOY1EXERCISE
I1NEED1A1GOAL1TO1EXERCISE
I1PREFER1EXERCISE1OUTSIDE
I1GET1BORED1EXERCISING
I1HAVE1TO1DO1TWO1THINGS1AT1ONCE1TO1EXERCISE
I1LIFT1WEIGHTS
I1ONLY1DO1AEROBIC1EXERCISE

MEDICATIONS: ________________________________________________________
______________________________________________________________________
______________________________________________________________________

SUPPLEMENTS:_________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

I1ATTEST1THAT1EVERYTHING1IN1THIS1FORM1IS1TRUE1AND1THAT1I1UNDERSTAND1THAT1EVERY1
ESTHETIC1TREATMENT1IS1DEPENDENT1ON1FOLLOWING1THE1PRESCRIBED1POST1TREATMENT1
INSTRUCTIONS1TO1ACHIEVE1THE1DESIRED1RESULTS.

SIGNATURE:______________________________1DATE:_________________
LEFT

IXLIPO1TREATMENT1FLOWSHEET

AREA1TO1BE1TREATED:_______1
____________________________________
DISTANCE1FROM1FLOOR:11TOP:_________ MIDDLE:______ BOTTOM:_______

RIGHT CHANGE11R 11LEFT CHANGE1L

MEASUREMENT BEFORE AFTER BEFORE AFTER INITIAL
#1 DATE1:_______
TOP
MIDDLE
BOTTOM
#2 DATE:_______
TOP
MIDDLE
BOTTOM
#3 DATE:_______
TOP
MIDDLE
BOTTOM
#4 DATE:_______
TOP
MIDDLE
BOTTOM
#5 DATE:_______
TOP
MIDDLE
BOTTOM
#6 DATE:_______
TOP
MIDDLE
BOTTOM
#7 DATE:_______
TOP
MIDDLE
BOTTOM
#8 DATE:_______
TOP
MIDDLE
BOTTOM
DATE:_______ NAME:_______________________ BIRTHDAY:_________
ALLERGIES:_____________________________________________________________
BP:________ BEGINNING1WEIGHT:______ GOAL1WEIGHT:________
HT:________ BMI:_______
#1Alcoholic1drinks/day:____ #1Alcoholic1Drinks/Week:____
Do1you1Smoke?:_______ What?____________ How1Much?___________
Do1you1take1THC1(Marijuana)1in1any1form?_______
#1Meals/Day:_______ #181oz1glasses1of1Water/Day:_____
Type1of1Diet:_______________________
Did1You1Have1a1Hysterectomy?_______ Are1You1in1Menopause?1_____
Do1you1Receive1Testosterone1Pellets?____ Do1You1Take1HRT?_____1List:___________

MEDICATIONS: _________________________________________________________
______________________________________________________________________
______________________________________________________________________
SUPPLEMENTS:_________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

MEDICAL1PROBLEMS:____________________________________________________
_____________________________________________________________________
_____________________________________________________________________
BARIATRIC1SURGERY?11Y111N GLUTEN1INTOLERANCE:1Y11N

FAVORITE1EXERCISE:________________________________ COLOR1OF1EXERCISE:_____

NOTES:________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
IMPRESSION:___________________________________________________________
______________________________________________________________________
______________________________________________________________________
PLAN:_________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
WEIGHT1LOSS1DRUG:_____________________________________________________
DIET1PLAN:_____________________________________________________________
______________________________________________________________________
TAKE1SHAPE1FOR1LIFE1REFERRAL:1Y1N111DATE:_______
DIET1DIARY:11Y11N
EXERCISE1PLAN:_________________________________________________________
______________________________________________________________________
Color1of1Exercise:___________
IXLIPO:____________________________1111LIGHTS1ON:11Y11N111
DIM:_________ EndoDren:_______

RTO:___________________

SIGNATURE:________________________11DATE:_________
 Important Information About i-Lipo
If you have any of the following medical conditions you should not have i-Lipo treatments:

• Pregnancy
• Current Cancer with involvement of lymph nodes
• Pacemaker or Defibrillator
• Hepatitis, Alcoholic Liver Disease, Cirrhosis, fatty liver disease.
• History of a heart attack
• Untreated Hypertension
• Lymphedema
• Active Auto immune disorder
• 1IDDM

If you have any of the following conditions you might not experience optimal effect from i-
Lipo, or are likely to have mild complications.

• Type 2 Diabetes
• Epilepsy
• Tattoos
• Thyroid disorders that are untreated
• Very dark skin
• Metallic or other implants
• Open wounds and skin irritation

i-Lipo results are best in patients who are well hydrated, and who exercise for at least an hour
after the treatment.

i-Lipo results are improved with the use of BioBalance i-Lipo Serum before and after for a
week.

I have read the Informed Consent and understand the risks of the i-Lipo machine.

Name Date

________________________________________________________________________

K"Maupin"11/2011
 I-Lipo Patient Instructions
Pre and Post i-Lipo Procedure

It is essential that you follow these instructions for optimal results from i-Lipo treatments!

One week prior to treatment

• Liberal water intake: More than 32 ounces/day
• Take all medications, even diuretics
• Watch appetite. Do not binge eat!
• Use i-Lipo serum twice daily on the area to be treated
• So not drink alcohol the night before i-Lipo.

Morning of treatment= prior to treatment

• Drink 24 oz of water (coffee, tea, cola does not count as water!) before the
procedure
• Do not take diuretics until day after treatment (eg. Lasix, maxide,
hydrochlorothyazide)
• Take normal medications
• Only apply i-Lipo serum on the area to be treated
• Wash the area to be treated before applying i-Lipo serum
• Remove jewelry in the area of treatment, eg belly button rings, earrings
• Wear clothing that will easily expose the area of treatment

During i-Lipo treatment

• empty bladder immediately before i-Lipo
• turn off phone and relax
• you may have another service during i-Lipo ….Like facial waxing, hydrating
facial, or jetpeel.
• Remember, i-Lipo does not hurt!
Immediately after treatment
• Apply biobalance i-Lipo serum over area treated, and massage toward the lymph
node where the stimulator was. Apply twice a day.
• Immediately after i-Lipo: You must participate in aerobic exercise—walk on a
treadmill, cycle, run, or participate in any aerobic exercise for 30-60 minutes. The
longer the exercise the more likely it is that the fat that was mobilized will leave
the body permanently! Drink another 36 ounces of water after i-Lipo.
• Do not drink alcohol! Do not binge eat!

Day after treatment

• Continue liberal water intake
• Resume all medications, even diuretics
• Control appetite as it may be increased from rapid fat loss…do not increase
normal calories!
• Use biobalance i-Lipo serum twice daily over the area of treatment, and massage
in.

For increased appetite:

• Avoid caffeine
• Use “lights on”, 2 packets/day to decrease hunger and stimulate lymph system
• Eat high protein diet
• Take shape for life shakes help
• Take dmx appetite control

Possible symptoms after i-Lipo:

1. Diarrhea—when you successfully remove fat from your body it has to be removed
in your stool. You may or may not notice an increase in bowel movements but the
bowel is how fat leaves the body. Diarrhea will not continue longer than 36 hours,
and should be mild. (it is a good sign that your body is removing the fat quickly!)

2. Increase in urination—loss of water from your tissues is normal after i-Lipo and is
a good sign that you are removing fat from your body. Fat enters the blood from
the lymph system, increases the “thickness” of the blood (oncotic pressure) and
pulls water from tissues to carry the fat to the bowel for removal.
 3. Swelling is unusual:—Apply biobalance i-Lipo cellulite serum in light strokes
over the area treated toward the lymph nodes that were activated with the probes

4. Feeling of flu like symptoms—this symptom is rare. Flu-like symptoms occur

when toxins in the fat are removed through the lymph system, and this temporary
and fleeting symptom is a sign that your body is removing the toxins along with
the fat!

5. Hunger—just like when you exercise, have lipo-suction or lipo-dissolve, you may
have an increased hunger after treatment. This is your body attempting to return to
normal by reaccumulating fat. Do not increase your food! Avoid carbohydrates,
especially alcohol! Eat a low carb, low animal fat diet and drink lots of water and
exercise to keep the fat from reforming.

Remember, with i-Lipo you lose a significant amount of fat from one area of your body,
and the dramatic change is permanent if you follow the directions above.

Do not reverse this loss by drinking alcohol, over eating or carb loading! During the time
of treatment, avoid alcohol and avoid carbs and binge eating so the change may become
permanent! This will take about a month.

Any other body sculpting procedure requires the same type of behavioral changes!

Kmaupin 1/12
 i-Lipo cellulite serum

i-Lipo serum is used to augment the fat loss and mobilization out of the body by
stimulation of the lymph disposal of fat.

The contents of i-Lipo serum are all botanical, and promote the removal of the fat into the
lymph system.

Lymph drainage is stimulated and blood circulation is promoted by this serum, before and
after the treatment.

Two pumps of i-Lipo serum covers the average surface area that is treated by one i-Lipo
treatment area.

How to use:
• Massage into area twice dayly before and after i-Lipo.
• Massage i-Lipo serum toward the lymphnodes that were stimulated.
• Exercise is critical to the process of dumping the mobilized fat into the intestines.
I-Lipo serum does not take the place of exercise, but augments it!
• Other active ingredients help with the lymph stimulation, increase circulaton,
decrease swelling in the area that can decrease the effectiveness of i-Lipo. Other
ingredients help penetrate the skin to carry active ingredients to the lymph system.
• Do not drink alcohol, or smoke cigarettes while undergoing treatment as they
decrease the outcomes of i-Lipo, and i-Lipo serum.
• I-Lipo serum can be used as an excellent cellulite serum to prevent and treat
cellulite on an ongoing basis.

Dr. Kathy Maupin, BioBalance Health

Medical Director of Halina-Andre Cosmeceuticals, Austin, TX

1/12
 I-Lipo Success Plan
I-Lipo will achieve IMMEDIATE loss of ¾ inches to 2 inches per treatment times 8
treatments per area, with NO PAIN, NO DOWN TIME, and few side effects. I-Lipo is an
incredible, and permanent way to lose fat, and sculpt the body.

Aerobic exercise after each treatment for >30 minutes is required for best results. We
offer referrals to select trainers for our patients who do not have established exercise
programs, for post treatment exercise.

Results are dramatically augmented by adhering to the following additional treatments:

• Take the supplement Lights On for Energy, Focus and rapid Fat Loss, as well as
Lymph drainage of fat (available in the office or at Dr. Maupin’s website,
www.dynamaxx.com/biobalancehealth).
• I-Lipo Serum included in an 8-treatment-package, or $50 in the office. Use before
and after I-Lipo treatments to improve outcome and increase lymph drainage.
• Take Shape for Life a Low carbohydrate diet plan
• Increased water intake before and after treatment

For best results and the most rapid loss of fat, and improved body sculpting immediately,
consider the additional treatments above.