Body sculpting Form

Body sculpting Form
TOU
Appointment date

Month Day Year
Date
Appointment time
EMAIL / NEWSLETTER
FULL NAME
Would you like to be added to our subscriber list in order to receive
AGE

PHONE
information about upcoming discounts, promotions, contests etc.?

YES! Sign me up! No, thanks
D.O.B.
AGE
ADDRESS
Have you ever had any weight loss treatments previously?

Yes No
If yes, please specify
What would you like to achieve from your treatment?
Do you exercise? If yes, how ofter and what type?
MUSCLE
WHAT BODY AREA/S WOULD YOU LIKE TO FOCUS ON?
VISCERAL FAT LEVEL
lawer back

Metal Electrical Wire Birth Control Cosmetic
innertights
thinning products and/or drugs that thin the blood?

Yes No
FRONT
BACK
Do you currently follow any specific diet system?

Yes No
If yes, please describe the diet system
List any medications, supplements, or herbal remedies you currently take
treatments if you have

Yes, before 8am Do you eat breakfast? Yes, 3 to 4 bottles daily Yes, between 8am and 10am After 10am Yes, 5 to 6 bottles daily Yes, more than 8 bottles daily No, I do not eat breakfast Heart Disease No, I do not drink water regularly Hypertension Diabetes No, I do not drink water at all Poor Blood Circulation
How often do you consume alcohol?

Do you have type 1 or type 2 diabetes?

Do you have any known liver disorders?
/wounds in treatment area

Hyperlipidemia Daily Weekly Monthly Ocassionally Never lipids in the blood Pregnancy Pace maker & Metal Implants Skin Inflammation Abdomen during Vascular Veins
Do you have any known kidney disease?
Do you have photosensivity to sun exposure?

Yes No Yes No Yes No Yes No Yes No No Yes Yes No Yes No Yes No Yes No Yes No
if yes, do you currently on chemotherapy?

Have you had cancer in the past 12 months?

Do you have any thyroid problems?

Do you have high blood pressure?

Do you have any cardiovascular conditions?

Do you have any medical devices, implanted

including but not limited to hearing aids, a pacemaker or hormonal pellets? if yes, please list
Are you currently pregnant or nursing?

Yes No
When was the first day of your last menstrual cycle?
This form is completely confidential. Completion of form gives the general state of health and assists our specialist in directing a customized course of treatment for you. The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any any existing or past health conditions.

Client Signature Therapist Signature
Appointment date

Month Day Year
Date
Appointment time
EMAIL / NEWSLETTER
FULL NAME
AGE

PHONE
Would you like to be added to our subscriber list in order to receive information about upcoming discounts, promotions, contests etc.?

YES! Sign me up! No, thanks
D.O.B.
AGE
ADDRESS
Have you ever had any weight loss treatments previously?

Yes No
If yes, please specify
What would you like to achieve from your treatment?
Do you exercise? If yes, how ofter and what type?
MUSCLE
WHAT BODY AREA/S WOULD YOU LIKE TO FOCUS ON?
VISCERAL FAT LEVEL
lawerhack

Metal Electrical Wire Birth Control Cosmetic
Are you using any skin thinning products and/or drugs that thin the blood?

Yes No
FRONT
BACK
Do you currently follow any specific diet system?

Yes No
If yes, please describe the diet system
List any medications, supplements, or herbal remedies you currently take
treatments if you have

Yes, before 8am Do you eat breakfast? Yes, 3 to 4 bottles daily Yes, between 8am and 10am After 10am Yes, 5 to 6 bottles daily Yes, more than 8 bottles daily No, I do not eat breakfast Heart Disease No, I do not drink water regularly Hypertension Diabetes No, I do not drink water at all Poor Blood Circulation
How often do you consume alcohol?

Daily Weekly Monthly Ocassionally Never
abnormally high

Hyperlipidemia
Do you have type 1 or type 2 diabetes?
/wounds in treatment area

Pace maker & Metal Skin Inflammation Vascular Veins
Do you have any known liver disorders?

Do you have any known kidney disease?
Do you have photosensivity to sun exposure?

Yes No Yes No Cancer Yes No Yes No Yes No No Yes Yes No Yes No Yes No Yes No No Yes
if yes, do you currently on chemotherapy?

Have you had cancer in the past 12 months?

Do you have any thyroid problems?

Do you have high blood pressure?

Do you have any cardiovascular conditions?

Do you have any medical devices, implanted

including but not limited to hearing aids, a pacemaker or hormonal pellets? if yes, please list

This form is completely confidential. Completion of form gives the general state of health and assists our specialist in directing a customized course of treatment for you. The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any any existing or past health conditions.

Client Signature Therapist Signature
Any medical or cosmetic procedure carries risk, complications and varied results as to the effectiveness of a particular treatment. The purpose of this document is to make you aware of the nature of procedure and its risks in advanced so that you can decide whether to go forward with any procedures/treatments.

Initially you will consult with the consultant to determine if you are a candidate for Body Sculpting Cavitation or other inch loss procedures. During this time you will have the opportunity to ask questions or voice concerns you may have regarding this treatment. If it is determined you are a candidate for any procedure, there will be a few preliminary steps consisting of: initial paperwork, measurements, pre and post treatment photos and suggested course of treatment. It is recommended that a client will need a minimum of 6 or more treatments for the therapy to achieve its desired effect. These treatment should be used in conjunction with a healthy diet and exercise. If you are not currently exercising you should consult a health care professional before beginning an exercise program to determine if your body is physically able.

Our treatments are non-invasive. During treatment there should be no discomfort. If for any reason during treatment that the client feels discomfort due to warmth or any discomfort, treatment will be terminated. Client should report this discomfort to technician immediately. If client chooses to continue through any discomfort, it is at the client's own risk and provider assumes no responsibility. Procedures are recommended for anyone over

The potential benefit of this treatment is body contouring without surgery. Problem areas or excess pockets of fat can be targeted, however the most commonly treated areas are the stomach, hips, flanks, and thighs. In clinical trials patients have averaged 2-5cm lost from there stomach, hips, and thighs. These results do vary and no guarantee is implied or suggested that desired results will be achieved.

By signing below, you certify that this procedure has been explained to you and your satisfaction. Any further questions can be directed to a your therapist.

Ihave reviewed this consent form. My consent and authorization for procedures are

strictly voluntary. By signing the informed consent form I grant authority for to perform the requested treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction.
Cosmetic indications for these procedures include but are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. You may experience increased redness to the area or light abdominal discomfort for up to 12 hours. You will be able to return to normal activities following the treatment. Any photos taken will be used to show the clients progress and may be used in marketing ads.
I have been informed of the potential risks and side effects of all procedures and treatments including but not limited to redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me and I fully understand.
I have been informed of the potential risks and side effects of all procedures and

treatments including but not limited to redness, swelling, heat sensitivity, pain,

increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me and I fully understand.
I understand that a minimum of 8 or more treatments may be required to achieve full results. At that point, I will be reevaluated to see if more sessions are needed in order to achieve realistic goals. Each body is different and may require more or less treatments depending on the client's diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.
I understand that a minimum of 8 or more treatments may be required to achieve

full results. At that point, I will be reevaluated to see if more sessions are needed in order to achieve realistic goals. Each body is different and may require more or less treatments depending on the client's diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.

No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the procedures I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion. The undersigned assumes all responsibility for behavior of self and their clients and agrees to abide by all Rules and Procedures of the property.

I further state that I am of lawful age and legally competent to sign this

aforementioned release; I understand the terms of

highest priority on the client's right to privacy. We do not disclose identifiable information

to any third party without your consent. Further, we do not sell, rent, or otherwise allow

the unauthorized outside use of personal information such as names, addresses, phone

numbers, or e-mail addresses in our database without your permission. Copies of this form

and signature will be valid as if original if this document is digitally scanned.
-5-2

Clear
I am over the age of eighteen and in apparently healthy condition. I understand the above potential risks and benefits of these services. I understand that injury can be unrelated to the technician, instruction or equipment.
I am over the age of eighteen and in apparently healthy condition. I understand

the above potential risks and benefits of these services. I understand that injury can be unrelated to the technician, instruction or equipment.
therapist name
not responsible for any claims or
BODY SCULPTINGPostfreatment Car
BODY SCULPTING
What to do after your treatment:
Maintain a healthy balanceddiet and regular exercise isimportant to maintain theresults Use an ice pack toreduce swelling,stiffness and bruising itMassage the treated areadaily to prevent fat andtoxins from becomingstagnant Avoid alcoholand caffeine for24h
BODY SCULPTINGPost freatment Car
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPostfrictment Car
BODY SCULPTING
III How to p What to do after your treatment:A

Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPast-freatment Co
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPost freatment Care
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults
BODY SCULPTINGPost-freatment Come
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPostfregamment Car
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h
Maintain a healthy balanced
diet and regular exercise isimportant to maintain theresults
Maintain a healthy balanced
diet and regular exercise is
important to maintain theresults

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPost-readment Car
BODY SCULPTING
What to do after your treatment:
Use an ice pack toreduce swelling,stiffness and bruising and caffeine for24h

Massage the treated areadaily to prevent fat andtoxins from becomingstagnant
BODY SCULPTINGPrefreatment Care
BODY SCULPTING
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

BODY SCULPTINGPrefreatment Care
BODY SCULPTING
How to prepare for your treatment
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

yet Wear loose fittingclothes on the day ofyour treatment

Shave any body hairon and around the

Wear loose fittingclothes on the day of

Shave any body hairon and around the

BODY SCULPTINGPrefreatment Care
BODY SCULPTING
How to prepare for your treatment
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

water the daybefore treatmentKD Drink at least 2L ofWear loose fittingclothes on the day ofyour treatment

Shave any body hairon and around the

BODY SCULPTINGPrefrestment Care
BODY SCULPTING
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

Drink at least 2L ofwater the daybefore treatmentyou

Wear loose fittingclothes on the day of

Shave any body hairon and around the

BODY SCULPTINGPrefreatment Care
BODY SCULPTING
How to prepare for your treatment
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

yat Wear loose fittingclothes on the day ofyour treatment

Shave any body hairon and around the

BODY SCULPTINGPrefreatment Car
BODY SCULPTING
How to prepare for your treatment

Drink at least 2L of How to prepare for your treatment
yet Wear loose fittingclothes on the day ofyour treatment

Shave any body hairon and around the

BODY SCULPTINGPrefreatment Care
BODY SCULPTING
How to prepare for your treatment
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

BODY SCULPTINGPrefreatment Car
BODY SCULPTING
Aviod heavy meals theday before and do not eat2h before treatment

Remove any lotionfrom your skinbefore treatment

before treatmentyes water the day Drink at least 2L ofWear loose fittingclothes on the day ofyour treatment
Shave any body hairon and around the

Drink at least 2L ofwater the daybefore treatmentytsWear loose fittingclothes on the day of
Shave any body hairon and around the
APPOINTMENT CANCELLATION POLICY
Dear Client, We strive to render excellent care to you and the rest of our clients. Your care and treatment is a priority for us. We also ask that you respect your specialist's time and expertise as well.

In an attempt to be consistent with this, we have a Cancellation Policy that allows us to schedule appointments for our clients, with respect for your time, the next client's time, and the specialist's time.

We request that you give a notice not later than 24 hours prior your scheduled

appointment in the event that you can not make it. If the client misses an appointment without contacting us, it is considered a missed or "No Show' appointment. Additionally, if a client is more than 15 minutes late for an appointment, it will be considered as" No Show" appointment, and that appointment will be rescheduled. Also, if you miss more than 3 (three) appointments, we reserve the right to charge you a fee of $

non refundable deposit will be paid at time of making appointment

and will be taken off at the time of the appointment.

If you have questions regarding this policy, please let us know, and we will be happy to clarify our policy for you.

I have read and understand the Appointment Cancellation Policy, and I agree to be bound by its terms. I am aware that my credit card will be charged for the missed appointment, and I agree to this terms.
Cancellation Policy.
Client Signature

Clear
Receptionist Signature

Clear
Date

Month Day Year
Date
COVID-19 LIABILITY RELEASE WAIVER
THIS FORM MUST BE COMPLETED AND SIGNED BEFORE TREATMENT

The World Health Organization has declared the novel Coronavirus (COVID-19) a worldwide pandemic. Due to its capacity to transmit from person-to-person through respiratory droplets, the

government has set recommendations, guidelines, and some prohibitions which
company name
adheres to comply. Symptoms of COVID-19 include:
Symptoms of COVID 19 include
suspected and/or confirmed case of the Coronavirus (COVID-19
misinformation on this form or the health history provided by each client.

I, nor members of my household, have not experienced any of the symptoms listed above within I, nor members of my household, have not travelled internationally in the last 30 days. I,nor members of my household, do not believe that we have been exposed to someone with a I, nor members of my household, have not been diagnosed with the Coronavirus (COVID-19) The venue cannot be held liable from any exposure to the Coronavirus (COVID-19) caused by I understand that due to the frequency of visits of other clients, the characteristics of the virus,
and the characteristics of these services that I have an elevated risk of contracting the virus simply by being in the esteblishment. To prevent the spread of the contagious virus and to help protect eavh other, I understand that I must follow the esteblishment's guidelines: Reschedule appointment if you are feeling unwell; No additional guest is allowed; Wearing a mask is required upon arrival and during the entire procedure; Wash hands upon arrival; Limit conversation during the procedure.

By signing below, I agree to each above statement and release the venue and its employees from any and all liability for the unintentional exposure or harm due to Covid-19 and other communicable
Name (Printed)
Date

Month Day Year
Date
Name (Signature)

Clear
PHOTO & VIDEO RELEASE FORM
hereby grant and authorize the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all

pictures, video, and/ or audio taken of me to be used in and/ or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print or digital communications without payment or any other consideration.

This authorization extends to all languages, media, formats, and markets now known and

I will be consulted about the use of the photograph and/ or video recording for any purpose

other than those listed below:

promotional materials; printed and/ or digital advertisements; educational presentations or courses; informational presentations; online educational courses;

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Full name
Street address/ P.O. Box
City
Postal Code
Email address
example@example.com
Phone
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Body sculpting Form

TOU

EMAIL / NEWSLETTER

MUSCLE

WHAT BODY AREA/S WOULD YOU LIKE TO FOCUS ON?

FRONT

BACK

EMAIL / NEWSLETTER

FULL NAME

MUSCLE

WHAT BODY AREA/S WOULD YOU LIKE TO FOCUS ON?

FRONT

BACK

BODY SCULPTINGPostfreatment Car

What to do after your treatment:

BODY SCULPTINGPost freatment Car

What to do after your treatment:

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPostfrictment Car

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPast-freatment Co

What to do after your treatment:

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPost freatment Care

What to do after your treatment:

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPost-freatment Come

What to do after your treatment:

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPostfregamment Car

What to do after your treatment:

Maintain a healthy balanced

Maintain a healthy balanced

diet and regular exercise is

BODY SCULPTINGPost-readment Car

What to do after your treatment:

APPOINTMENT CANCELLATION POLICY

COVID-19 LIABILITY RELEASE WAIVER

PHOTO & VIDEO RELEASE FORM