Body Contouring & Butt Lift Form

Body Contouring & Butt Lift Form

Cavi Lipo, RF Skin Tightening, Laser Lipo, Non Invasive Butt Lift
Full Name*

First Last
E-mail*
We will never SPAM or sell email addresses to third parties.
Birthdate:*
ex. 01/05/1960
Phone:*
ex. 555-555-5555
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who referred you to skinSPArations?*
Please read and initial each of the statements below:
I certify I am over the age of 18. I have voluntarily elected to receive body contouring after the nature and purpose of this treatment has been explained to me.*
Initial
I understand that body contouring can be used to reduce fat deposits, but is not intended to be a weight loss solution. I recognize there are no guaranteed results and every body responds differently to treatment*
Initial
I have the Before/After Care instructions and FAQ section on www.skinSPArations.com and am informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications*
Initial
I understand a minimum of 72 hours is required between treatments and WATER intake is necessary to assist in fat removal and achieving my goal.*
Initial
I understand results will vary during my mensuration and not recommended to have this done during my cycle*
Initial
I understand that the following conditions preclude me from having this treatment at this time and verify that none of the following conditions apply to me at this time: • Cardiac issues • Cancer • Infected, inflamed, or swollen skin • Metallic implant (pacemaker) • Pregnant/Lactating*
Initial
understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: • Redness • Swelling • Irritation • Skin reaction • Increased heart rate*
Initial
Have you had any of these health conditions in the past or present? *

Diabetes (Type 1 or Type 2)Kidney or Liver DIsorderSystemic diseaseCancerPhotosensitivity to Sun ExposureHigh Blood PressureVaricose veinsCardiovascular ConditionsMetal implantsNon Metal ImplantsBirth Control ImplantsNONE, I am in good health
List all oral VITAMINS or HERBS you take daily:*
Do you have any allergies? If yes, please explain:*
Do you currently have any rash, windburn, sensitivities or other issues on the area being treated? If yes, please explain:*
What concerns would you like addressed today?*
Do you want to lose body fat? If yes, from what area:*
Do you want to tighten skin on your body? If yes, from what area*
Do you want to reduce cellulite? If yes, from what area*
Please list your regular exercise habits:*
Please describe your current dietary habits:*
How many ounces of water do you drink daily?*
I understand, have read and completed this questionnaire truthfully. I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I understand that withholding information or providing misinformation may result in contraindications and/or irritation to the skin from treatments received. I am aware that it is my responsibility to inform the aesthetician of my current medical or health conditions and to update this history. The treatments I receive here are voluntary and I release skinSPArations and/or the skin care professional from liability and assume full responsibility thereof.
I understand and agree*
Initial
To cancel an appointment please test 920-216-5338 or email skinSPArations@gmail.com at least 24 hours prior to your appointment. Cancellations or Reschedule less than 24hrs notice will be subject to the following:
- First occurance 50% charge of service, after that 100% charge of service
- No Show or Missed Appointments 100% charge of service
I agree to the cancellation policy*
Initial
I understand before/after photos will be taken for legal and progession purposes as and grant permission to skinSPArations to use photos of my progress for marketing purposes on www.skinSPArations.com or other business listing pages.
I agree to the photo release*
By signing below, I agree to the following:
I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.
Client Full Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Should be Empty: