Body Sculpting Consent Form

Thank you for your interest in having your body sculpting procedure with us. We are with you on your desire to reach your goals for a better body that helps boost your confidence and bring a better lifestyle.

We have provided some information that can help you achieve your best results: Drink plenty of water before and after treatment and wear comfortable clothing.

3 days before treatment: DO NOT drink alcohol. DO NOT eat fat fried and spicy food, in order not be a burden on the liver and kidneys. Drink at least 1 liter of water per day. It is highly recommended to drink 1 liter of water 2-3 hours before treatment.

Following treatment: Drink at least 1 liter of water per day. This is important for better lymph flow. Eat a balance diet. DO NOT abuse the consumption of alcohol, coffee, fats or carbohydrate - rich foods. Maintain an active lifestyle.

Please take note that results may vary for the treatment. During the treatment, you might feel a warm discomfort. If it's not tolerable, please advise our technician. At an average, you can expect a reduction from 0.5 inches to as much as 2.0 inches after a treatment.

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

MaleFemale

Marital Status

SingleMarriedWidowedDivorced

Date of Birth*

Date

Age

Contact In Case Of Emergency

Name*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Relationship

Height

Current Weight

Goals

Treatment Interested in

Areas to be treated

Areas to avoid

Medical History

	Yes	No
Are you pregnant or nursing?
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?
Do you have advanced untreated diabetes?
Do you have uncontrolled Hypertension?
Do you have any kind of heart condition?
Do you have hemophilia (blood clotting condition)?
Do you have a keloid scar?
Do you have any infectious disease or tuberculosis?
Do you have a pacemaker?
Immunosuppressive diseases such as HIV, AIDS?
Immunosuppressive medication?
Peacemaker or other implanted electronic devices?
Heart Disease?
Any surgical procedure in treatment area within the last 3 months?
Skin cancer?
Premalignant moles?

Are you taking any medications? Please explain.

Do you have any allergies? Please explain.

If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.

Please explain any conditions marked above.

Reminder:

Please make sure that there are no metal instruments that are present on or in your body during the scheduled treatments. If you have any heart or liver problems, uncontrolled high blood pressure, or cancer or undergoing radiology treatments, please see your doctor first. However, if you have a pacemaker, it is unfortunate that we cannot proeed with any of the services that we offer.

Agreement: although we take every precaution to ensure your safety and well-being before, during and after your service, please be aware of the possible risks below. Please read carefully and sign at the end.

I understand that body contouring can have certain side effects such as skin redness, swelling, tenderness, cardiac issues.. etc.

I understand that body contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve medical conditions.

I giver permission to my therapist or technician to perform the procedure we have discussed and will hold her and her staff harmless from liability that may result from this treatment.

I have read and understand the post-treatment home care instructions. I am willing to follow recommendations made by my technician for home care regimen that can minimize or eliminate possible negative reactions.

I understand that in the event I have questions or concerns regarding my treatment, I will consult the technician and Naturita Therapy Spa, LLC. Immediately .

Signature*

Lateness and Cancellation Policy

Our time is very valuable. To ensure we can provide all our clients with excellent service, we ask that you be on time to all your appointments. Please arrive at least 5 minutes prior to your scheduled time to ensure you receive your full appointment time. Please wait in the hallway if we are finishing up with another client.

In the event that you shoul be tardy, please be aware that if you are 15 minutes or more late to your appointment, you will be cancelled and charged 50% of service. You will need to reschedule, no exceptions.

In the event that you need to cancel or reschedule your appointment, we asked that you notify us at least 48 hours in advance of your scheduled appointment.

*We reserve the right to charge 50% of the scheduled service price when cancelling or rescheduling less than 48 hours prior to your appointment.

A CARD ON FILE IS REQUIRED TO BOOK ANY SERVICE.

The satisfaction of our clients is our main priority. We offer prompt solutions to any problems or concerns that may occur. We DO NOT offer refunds, credits, or exchanges for products sold or services rendered.

If, for any reason, you feel dissatisfied with any of our services, please bring this to our attention. We appreciate feedback, negative or positive, from our clients to better serve you.

I understand and acknowledge Naturita Therapy Spa, LLC. Policy regarding lateness and appointment cancellations.

Customer Privacy Policy

We value your privacy. We do not disclose your personal information or share with others outside entities unless otherwise authorized by you. Your information is used for internal statistics, marketing or educational purposes. We do not send spam emails. We only communicate with our clients and potential clients regarding new services, price changes, special offers, and appointment notifications.

Photo Release Waiver

I understand that for legal purposes, Naturita Therapy Spa, LLC. Will take phots before and after the service is complete.

I hereby grant and authorize Naturita Therapy Spa, LLC to take, edit, copy, publish, distribute and make use of any and all pictures or video taken of me to be used in an/or for legally promotional materials including, but not limited to, newsletters, flyers, poster, brochures, advertisements, fundraising letters, annual reports, press kits and submissions to journalist, websites, social networking sites, and other print and digital communication, without payment or any other consideration. This authorization extends to all languages, media, formats and markets or hereafter devised. This authorization shall continue indefinitely.

I understand and agree that these materials shall become the property of Naturita Therapy Spa, LLC and will not be returned.

I hereby hold harmless, and release Naturita Therapy Spa LLC, from all liability petitions and causes of action.

CONSENT I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I understand that non-invasive surgery procedures do not rid the body of visceral fat. I hereby release and forever discharge the Clinic, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, the Clinic for any liabilities, damages, injuries whether seen or unforeseen. I understand that any procedure under the Clinic does not constitute medical treatment or cure to any illness. By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence.

I have fully read and understand the contest of this consent form to its entirely including my responsibilities detailed throughout this document. I have been given the opportunity to ask questions abou the products, application procedure and any risks or hazards involved.

Name*

First NameLast Name

Signature*

Date*

Date

Body Sculpting Consent Form

Important information

Lateness and Cancellation Policy

Customer Privacy Policy

Photo Release Waiver