Medical History - Body Sculpt Studios / My Bella Spa, LLC.

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Board Certified Plastic Cosmetic Non Board Certified Plastic Other

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Yes No Not Sure

Yes No Not Sure

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Asthma / Respiratory Condition / Shortness of Breath Allergies Cardiac disease Cancer Diabetes Hypertension Anemia Epilepsy Pain Nausea Dizziness Gastrointestinal Issues Regular Bowel Movements Thyroid Gland Disfunction Pregnant or Breastfeeding Compromised Immune System Skin Lesions Metal Plates or Screws in Body Open Wounds None of the Above Other

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CONSENT FOR SERVICES: I give Consent for the Manual Lymphatic Drainage procedure, Post Operative services, or Body Contouring procedure that I have purchased. I acknowledge that these services are not a substitute for a medical examination or diagnosis and I should see a doctor for any medical concerns I may have. I agree to update the staff of any changes in my health and release all staff and My Bella Spa / Body Sculpt Studios from any liability if I fail to do so.

SPA POLICY: 24 hour Cancellation Policy for all appointments. Must cancel before 24 hours to Avoid $50 Cancellation Fee. Last-minute cancellation will be charged $50 cancellation fee to reschedule appointment. LATE 15 minutes will be charged $25 Late Fee. RESCHEDULING: Multiple Rescheduling will be charged $50 each time. NO-SHOWs will be charged the ENTIRE COST of the Session and will be counted against treatment plan resulting in the loss of the Session. All Services and Deposits are Non- Refundable. There are No Refunds or Exchanges on any Services or Deposits. Refunds will not be issued.

ALL SERVICES & SALES ARE FINAL. There are no refunds on any services. No exceptions. All payments are final. Refunds will not be issued. DEPOSITS: There are no refunds on any deposits.No exceptions. All payments are final. Refunds will not be issued.

I confirm that all answers on this form are true and correct to the best of my knowledge. I understand that there are no guarantees to the results of this treatment. I understand to achieve maximum results may require several treatments. I understand that temporary hyperpigmentation/hypo pigmentation on rare occasions may occur as a result of the Taping Wrap, Micro-needling or hot / cold treatments, and various other services.

FACE ALLOWED : I understand photos will be taken for medical purposes to manage my treatment and used for my patient care plan, marketing, educational literature and training purposes. FACE ALLOWED - I agree to allow my face to be shown and my identity to be revealed for medical purposes to be used for my patient care plan, marketing, educational literature and training purposes. I acknowledge that I have a right to change my mind and discontinue authorization at any time by submitting it in writing via email to fatloss@mybellaspa.com NO FACE: I understand photos will be taken for medical purposes to manage my treatment and used for my patient care plan, marketing, educational literature and training purposes. NO FACE - My face will not be shown, nor any tattoos or identifiable markings or scars revealing my identity. I acknowledge that photos will be taken for medical purposes to manage my Treatment and patient care plan ONLY.