Cavitation Consultation Form

Cavitation Consultation Form
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Date of Birth

MonthDayYear
Date
Occupation
Ultrasonic Cavitation Treatment Areas (Please select all that apply)

AbdomenUpper BackArmsCalvesNeckWaistButtocksLower BackHipsInner/Outer Thighs
Medical Background (Check all that apply)

Pregnant/ NursingEpilepsyInternalHigh CholesterolCancerCardiac/ Vascular ProblemsAbdomen OperationAllergic to Zinc/ NickelAcute inflammationUnhealed WoundsHigh/ Low Blood PressureHemophiliaMelanomaTransplantNeurological DisorderThrombosis/ ThrombophlebitisAnticoagulantsKeloidsInfectionTuberculosis/ Other Infectious DiseaseDiabetesHeart/Kidney/Liver DiseasePlastic/ Bone Cement/ Large Metal ImplantCurrently Taking MedicationsRecreational Drug UseOther
By signing below, you agree to the following:

have completed this form to the best of my ability and knowledge and agree to inform my esthetician of any changes to the information listed on all pages of this cavitation intake form. I have been informed of and understand the contraindications to the requested treatments and agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform my esthetician of any discomfort I may experience during the requested treatment to allow them to adjust accordingly. I agree to waive all liabilities toward my massage therapist Beverly Holloway/ Bodyworks by Design LLC for any injury or damages incurred due to any misrepresentation of my health history.
Body sculpting increases flow of both the lymphatic and circulatory systems, and it also helps with cleaning bodily tissues. The main use of body sculpting is skin tightening, diminishing the appearance of cellulite, and inch loss. 1-3" inch loss per treatment is common although some people may see a delay in results. For best results, it is recommended that a series of 9-12 treatments per area be completed. Some individuals may require more treatments to maximize results. There should be at least 3 days between treatments. This service does not result in weight loss but inch loss. The inches may return if the client goes back to old habits. Proper diet, exercise and water intake is crucial in maintaining results.
I understand that body sculpting treatments are not recommended if I am pregnant, breast feeding, have a lymphatic disorder, acute illness, metal implants, pacemaker, or are currently being treated for active cancer.*
I understand that neither office personnel of Bodyworks by Design LLC nor this agreement provides a guarantee of results. This agreement deals solely with the services to be rendered and the fees to be paid for the care as provided. Your payment obligation is not contingent upon the outcome of services.*
I understand that Bodyworks by Design LLC is using 9 in 1 cavitation/radio frequency/ vacuum therapy/ laser lipo machine on me during this service at my own risk. Should I sustain an injury while using the equipment, I agree not to hold Bodyworks by Design LLC responsible.*
I understand and acknowledge that payments for the above services are non-refundable.*
By my signature below, I certify that I have read and understand the contents of this consent form.*
I further agree to provide Bodyworks by Design LLC 24 hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only.*
There are no refunds if I am responding to a treatment and decide to stop treatments.*
Should I decide to add a treatment, that treatment will be considered an additional and separate treatment.*
I agree to inform and notify immediately Bodyworks by Design LLC should any information regarding my health history past and present change.*
I agree that I have answered all the questions about myself and health history to the best of my abilities and knowledge.*
I certify that the information on my cavitation intake form is true, and acknowledge that any misrepresentation of my health history may result in injury or death. If any of the information about me or my health history is false, misleading, or undisclosed, I agree that Bodyworks by Design LLC will not be held liable.*
Avoid eating two hours before and after treatment sessions and avoid heavy meals on the treatment days.
Drink plenty of water.
Limit carbonated drinks, coffee, and tea during treatment period.
Avoid fasting (fasting may delay results and the body's ability to break down fats)
Within two hours of a treatment, perform 30-45 minutes of cardio-vascular exercise in order to create the energy demand that will facilitate metabolism.
Possible side effects include diarrhea, increased urination, flu-like symptoms, and increased hunger. If you have any concerns, please don't hesitate to contact our office at 321-356-5177.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: