• Body Contouring Consent Form

    Body Contouring Consent Form

  • Format: (000) 000-0000.
  • Date of birth*
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  • Must be over the age of 19 years old to do this service. 

  • Any chronic medical conditions which we should know about?*
  • Any allergies?*
  • Do you have, or have you had, any changes in medical history recently?*
  • Do you have hearing aids, pacemaker or hormone pellets (where) or metal/medical devices implanted?*
  • Do you have or have had cancer in the last 12 months?*
  • If yes, are you currently on chemotherapy?*
  • Are you pregnant?*
  • If yes, are you nursing?
  • History of Colon problems including protruding/distended belly?*
  • Have you had any surgeries?*
  • Any medication we should be aware about?*
  • Do you have any Botox, fillers, implants, or other injectables?*
  • Are you currently dieting?*

  • Typical Daily foods and drink intake?

  • What are your stress levels?*
  • Please Check the Following that Apply
  • Any medication we should be aware about?*

  • Please Read, Understand and Sign the Following:

  • Although every precaution will be taken to ensure your safety and wellbeing before, during and after your session, please be aware of the following information and possible risks.

    Body sculpting increases flow of both the lymphatic and circulatory systems, and it also helps with cleaning of the tissues. The main use of body sculpting treatment is inch loss, diminishing of cellulite, and tightening of the skin.

    Benefits:
    Lose 1-3 inches per treatment with state-of-the-art equipment. Benefits are often immediate but may be delayed in some people.

    For Best Results:
    A series of 9-12 body sculpting treatments is recommended per each area, but some individuals may require more treatments to achieve maximum results. There should be at least 3 days between each treatment. This is not a weight loss treatment, but an inch loss. The inches will only return if the client goes back to their old habits. Eating the right types of food, proper exercise, and drinking 8 glasses of water per day are always recommended. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar and alcohol for 2 days after each treatment.

    Precautions:
    Body sculpting treatments are not recommended if you are pregnant, breast feeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer. 

    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 Tu Lumia. 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 Tu Lumia 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 like medical advice, please see one of your medical doctors. 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).

  • I understand, acknowledge, and accept the statement above and have asked any questions if I did not understand anything.*
  • I understand that I am using the Frequency / Vacuum machine  provided at my own risk. Should I sustain an injury while using the equipment, I agree to not hold Tu Lumia responsible.*
  • I understand and acknowledge that payments for the above services are non- refundable. There are no refunds if I am responding to treatment and decide to stop treatments.*
  • understand that photographs and measurements will need to be taken in order to review and record results and will be kept in client file. For advertising purposes accept or decline below.*
  • Photo Advertising Consent -- “before and after” pictures for the purpose of documentation, potential advertising and promotional purposes without payment or any other form of compensation. I understand that my image may be edited, copied, exhibited, published or distributed. Photos, video and audio may be used for the following purposes: ~ Website advertising ~ Marketing purposes ~ Take home manuals ~ Social media platforms ~ Informational presentations ~ Educational purposes I will be consulted about the use of the photographs or video recordings for any other purpose other than those listed above.*
  • I understand that if I have any concerns, I will address them with my technician. I give permission for my technician to perform this service and will hold Tu Lumia harmless & nameless from any liability that may result from this session. I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my technician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my service, I will consult my technician immediately. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered. I understand the procedure and accept the risks. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.*

  • I Have Read and Completely Understand this Consent Form

  • Date*
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