Body treatments

ILLUME Skin Spa

Consent Form / Body treatments
Personal Information
Date

MonthDayYear
Date
Full Name*

First NameLast Name
Age*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone*

Area CodePhone Number
E-mail*
Referred by
**IMPORTANT INFORMATION BEFORE APPOINTMENT**

We recommend combining treatments with a healthy lifestyle, for example; exercise, balanced diet, and water intake. Treatment results depend on a variety of factors, such as body type, lifestyle, metabolism, age and more. Different bodies respond differently to treatments; in some cases, an individual might not see a significant difference even after multiple treatments. Illume Skin Spa does not guarantee results, and by booking an appointment with us you acknowledge that. No compensation will be offered in case of dissatisfaction.
Treatments you are interested in? *

CryoSkin/ Cryo SculptingBody ContouringUltrasonic CavitationRadio FrequencyOther
Treatment Area*

Upper AbdomenLower AbdomenNeckArmsLegsInner ThighsOuter ThighsLower BackUpper BackHipsButtocksDouble ChinSkin TighteningFaceLiftOther
Medical Information:
Have you had cosmetic surgery*

YesNo
When
Type of surgery
Have you taken Accutane for acne in the past three months:*

YesNo
Are there any medical problems we should be aware of (HIV, AIDS)?*

YesNo
List current medications or vitamins you are presently taking and reasons*
Medical History*

Are you pregnant or nursing?Do you have any kind cancer?Are you epileptic?Do you have any cardiac or vascular problems?Do you have a wound that has not healed?Current or any history of internal bleeding?Do you have a pacemaker or other electronic device?Do you have any plastic or bone cement or any large metal implant?Have you had any abdomen operations?Abnormaly high or low blood pressure?Do you have high levels of Triglycerides (hereditary)?Are you allergic to zinc or nickel?Do you have hemophilia?Do you have melanoma?Do you have thrombosis and / or thrombophlebitis?Have you undergone a transplant?Do you have a Neurological disorder?Are you being treated with anticoagulants?Do you have any keloids?Do you have any kind of heart trouble?Do you have any current infection?Do you have any infectious disease or tuberculosis?Do you have advanced untreated diabetes?Do you have a communicable disease?Do you have any type of heart, kidney, liver disease?NoneOther
I do hereby agree to the following. I am allowing ILLUME SKIN SPA to take photos of my treatment and/or treated areas to be used to the purpose of monitoring my progress/use on ILLUME SKIN SPA website my identity will remain anonymous.*
Full Name
Cancellation Policy*

I AGREE THAT A 48 HOUR NOTIFICATION by phone call (please leave a voicemail if we don't answer your call) IS REQUIRED TO AVOID A $50 CANCELLATION FEE OR A $50 RESCHEDULING FEE. I UNDERSTAND THAT IF I AM 10 MINUTES LATE FOR MY APPOINTMENT IT WILL BE CONSIDERED A NO-SHOW AND THE CANCELLATION FEE WILL BE APPLIED. I AGREE TO THIS POLICY AND CONSENT THE SPA TO CHARGE MY CARD ON FILE THAT WAS PROVIDED WHEN BOOKING.
Signature*

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ILLUME Skin Spa

**IMPORTANT INFORMATION BEFORE APPOINTMENT**

IMPORTANT INFORMATION BEFORE APPOINTMENT