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Medical History
Full Name
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First Name
Last Name
Phone Number
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Email
*
example@example.com
Check the conditions that apply to you or to any members of your immediate relatives:
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Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
None
Check the symptoms that you're currently experiencing:
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Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Weight gain
Weight loss
None
Are you currently taking any medication?
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Yes
No
Do you have any medication allergies?
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Yes
No
Not Sure
What is your Gender?
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Male
Female
Do you use or do you have history of using tobacco?
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Please Select
Yes
No
How often do you consume alcohol?
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Daily
Weekly
Monthly
Occasionally
Never
What are your goals?(Weight loss, reduce cellulite, reduce stretch marks, etc*)
*
I give Amour Sculpting Body Bar, permission to take and use my before and after pictures for education and marketing purposes.
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Yes
No
Do you have any of the following conditions?
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Cancer/ Systematic Disease
Uncontrolled Hypertension
Diabetes
Life sustaining artificial heart/ lung
Auto immune disorder
Epilepsy/ Seizure Disorder
Thyroid Gland dysfunction
Herpes Simplex
Liver or Kidney Disease
Pacemaker, Defibrillator or Metal surgical implant
Pregnant or Breastfeeding
Menstrual Cycle(Time of treatment) or about to start
Blood clots or on long time blood thinners
Abnormal tissue growth(prone to keloid scarring)
Vascular conditions
Post Ileostomy
Osteoporosis, Fibromyalgia, Malignant Tumors,High cholesterol or Irritable Bowel syndrome
None
If you marked yes to any of these conditions, please provide more information. If you marked None, put N/A in the box below.
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Back
Next
Please list any known allergy, prescription drug or products your taking topically or ingesting. If this does not apply to you, please put N/A.
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By Signing You agree to following my pre-care and after care to get maximum results. Before any session you must Drink 2 liters of water, 2days before appointment and 3 days after, you must not drink alcohol 24 hours before or 72 hours after! Must not eat 2 hours before appointment! Must not eat fatty foods or drink caffeine 2 days before treatment and 3 days after! Must workout with treatment to get best results!
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I understand that taking the treatment is my choice and I can withdraw from the treatment at anytime, without giving any reason. I understand that diet, consistent exercise and wearing compression garments will help to achieve maximum results. I understand there are no refunds for any treatment. I understand the possible side effects such as but not limited to Excessive Thirst,Redness,Swelling,Hyperpigmentation, local pain, skin redness, swelling,numbness, damage to the natural skin texture (crust, blister, burn), fragile skin and bruising. I understand that these are usually rare and temporary, but if they do occur, there is a possibility of long term or permanent reactions. I UNDERSTAND THAT THIS IS A PROCESS THAT TAKES MULTIPLE SESSIONS AND THAT I MAY NOT SEE IMMEDIATE RESULTS RIGHT AFTER MY FIRST SESSION.
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I have read and understand the above statements
Signature
DISCLOSURE: These treatments are a process and multiple visits may be necessary in order to achieve the desired results. Multiple visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Amour Sculpting Body Bar does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, lactation complications, hypertriglyceridemia, hypercholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea.The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 25-28KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte's cell membrane. AFTER CARE : After care instructions must be followed explicitly. Failure to follow after care procedure instructions may compromise the final results of the treatment.
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I have read and understand the above statements
Signature
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Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications of this treatment. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies, prescription drugs or products I am currently ingesting or using topically.I have read and fully understand this agreement and all information detailed above. I understand the treatment and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement. I do not hold the technician (nor the establishment) responsible for any of my conditions that are present, or that may or may not arise in the future. I release Amour Sculpting Body Bar and its Body Contour Specialist from any and all liability from all treatments that will be provided to me
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I have read and understand statement above
Signature
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