Firming, Body Wrap, Infrared Sauna Blanket, Celluma Pro/Contour Treatments Intake Form

Name

First NameLast Name

Date

Date Of Birth

Date

Sex

Phone Number

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

Email

example@example.com

Are you currently under any medical treatment?

YesNo

If Yes, Please provide a brief description:

Do You Have Any Allergies To Latex, Medications, Herbal or Natural Supplements?

YesNo

If So Please List Them:

Do You Have or Have You Had, Any Changes In Medical History Recently?

YesNo

If So Please List Them:

Please check which applies to you. Items with an asterisk are contraindications and cannot receive the Infrared Sauna Blanket Treatment.

Do you have any allergies to Iodine (seafood, etc..)

YesNo

Explain

Have you ever had a reaction to any body treatment?

YesNo

Do you have any medical implants?

YesNo

Do you have any allergies?

YesNo

If yes, please explain

Are you taking medications?

YesNo

If yes, please explain

In consideration of receiving the BELLA FIRMING, BODY WRAP , INFRARED SAUNA BLANKET, CELLUMA PRO/CELLUMA CONTOUR TREATMENT(s) at Bella Day Spa, the undersigned:

(1) fully realizes that the body treatment(s) may have side effects, including but not limited to, skin irritation, skin redness, allergic reaction, dizziness, fainting, nausea, headache, change in blood pressure and change in heart rate;

(2) in spite of these possibilities, requests that the body treatment(s) be performed, and expressly consents to such treatment;

(3) herby releases and forever discharge Bella Day Spa from any and all claims, damages, and causes of action that may arise from the body treatment, including pre-body treatment(s) and post-body treatment(s) procedures; and

(4) agrees that this Release shall be binding on the undersigned, the spouse of the undersigned, and the heirs, legal representatives and assigned of the undersigned.

(5) Celluma Pro/Celluma Body Contraindications:
All photo sensitive drugs are a contraindication for Celluma. Allow 3-5 day before administering Celluma.
Do not use if client is on steroidal medication (injections only). Allow 3-5 day before administering Celluma.
Do not use over a pregnant belly or lactating breasts, but you can use over the face.
Do not use if client has history of epilepsy or seizures.
Do not use over any cancer or any known metastasized before getting clearance from their doctor(s).
Do not use on children under 12 years old.

The undersigned has read all of the terms of this Release and understands that he/she is signing a complete release and bar to any claim resulting from body treatment(s) at Bella Day Spa.

I agree to Bella Day Spa giving face/body treatment(s) under the terms and conditions described above. I also agree that these forms have been completed truthfully and to the best of my knowledge/abilities.

I Agree

Signature

Date

Firming, Body Wrap, Infrared Sauna Blanket, Celluma Pro/Contour Treatments Intake Form

Medical History

RELEASE OF LIABILITY