Body Sculpting Consent Form

Name

First NameLast Name

Phone Number

Area CodePhone Number

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I certify that I am over the age of 18?

YesNoOther

What is your goal

weight loss (less than30 lbs)weight loss (30 lbs +)inch lossOther

I understand that body sculpting can be used to reduce fat deposits, but is not intended to be a weight loss solution loss.

YesNo

I have voluntarily elected to receive body sculpting after the nature and purpose of this treatment has been explained to me.

YesNo

Have you ever had body sculpting services before?

YesNoif yes, please specifyOther

I give my consent for body contouring to be performed by Carolina Glam LLC. I understand Body Contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition.

YesNoOther

I understand that the following conditions preclude me from having this treatment at the time and verify that none of the following conditions apply to me at this time:

* I have no cardiac issues.

* I do not have any piercings in and agree to remove them prior to service

* Body Contouring should not be applied over inflamed, infected, or swollen areas of the skin.

* Body Contouring should not be applied over or near cancerous areas.

* I do not have a metallic implant (pacemaker)

* I am at least 6 months post pregnancy

* I am not pregnant or lactating

*I have not been on my menstrual cycle for the past 3 days

I understand that any procedure involves risk. Risks may include redness, swelling, irritation, skin reaction, or increased heart rate.

I have been honest and forthright about my medical history, and I am healthy to use the device. I do not have any disease or condition that may be negatively impacted by the Body Contouring device.

Acknowledgement: I understand each person has a different response to the Body Contouring treatment. The risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses. I understand that there are no guaranteed results.

I voluntarily provide my consent to partake in the Body Contouring treatment. Should any pain or discomfort occur I will immediately notify staff. I will not hold tech service provider liable for any irritation or effects of having thermal heat applied or any risk involved.

Please agree to the terms and conditions

I hereby agree to have body sculpting services by way of Body Cavitation, Radio Frequency, Vaccuum Therapy, Wood Therapy, Laser Lipolysis and or Sauna DetoxI understand and agree to the after-care instructions and for any unexpected circumstance that have happened due to not following these instructions are in my own risk.

AFTERCARE INSTRUCTIONS:

For three days following service I agree to avoid alcohol consumption
Limit Spicy foods
Drink room temperature water (at least 1/2 your body weight in ounces)

Terms of Acceptance & Liability

Please read carefully and understand the contents of this form. Ask us if you do not understand. When a client seeks Body Contouring services and when the service provider accepts a client, it is essential that both are seeking and working for the same goals. We expect our clients to take full responsibility for their decisions to participate in any of the services/programs offered by this office. We do not identify, diagnose, or treat ANY condition or disease. We have only one goal: TO OPTIMIZE YOUR BODY'S ABILITY TO FUNCTION NORMALLY AND OPTIMIZE YOUR FAT-BURNING POTENTIAL. By reducing bio-stress levels, we allow the body's inborn self-correcting mechanism to work at maximum efficiency to restore, maintain and promote wellness. We do not identify or diagnose any condition(s) or disease(s We offer no treatment for any condition(s) or disease(s We promise no cure from any disease(s) or condition(s) Instead, we facilitate your body's own self-correcting mechanism. It is essential that you speak to your doctor prior to making any decisions about altering any medical regimen you are currently following, changing your diet, taking supplements, or going on an exercise and/or weight loss program. Getting your doctor's approval prior to starting any service/program at our office is critical and solely your responsibility. Should any health condition arise while you are a client, we recommend that you immediately see the appropriate health care provider.

Any options that are rendered by the staff and/or head personnel should NEVER be construed as medical advice but merely as opinions. If you would like medical advice, please consult with your doctor. We will not deal with any medical condition. With your signature below, you understand and voluntarily accept these risks and agree that neither the service provider, its staff, or any of its partners will be liable for any injury to you, including, but not limited to, personal bodily injury, death, mental injury, economic loss or any damage to you, your spouse, or relatives resulting from any act of the service provider, and its staff or anyone else using the facilities and that you acknowledge the inherent risks of the positions, movement, dietary/nutritional programs offered to and done to you at the service provider, with respect to your current or past condition(s)

RELEASE OF LIABILITY Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company's behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company's gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind.

I hereby agree and authorize Carolina Glam LLC, the right to take, edit, alter, copy, exhibit, publish, distribute, and make any use any and all pictures, videos, and/or audio taken of me to be used in and/or for any lawful promotional material including, but not limited to newsletters, flyers, potters, brochures, advertisements, websites, social networking sites, and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now

I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electric copy.

Additionally, I waive the right to royalties or other compensations arising or related to the use of my image or recording.

I hereby hold harmless and release Carolina Glam LLC from all liability, petitions, and causes of action, which I, heirs representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

Date

Client Signature