Butt_Cupping_Consent_Forms

  • Butt Cupping Intake Form

  • General Information

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Medical History

  • Please check all that apply:
  • Do you have any other medical conditions that we should know about?*
  • Are you currently taking any medications (including, but not limited to, blood thinners)?*
  • Do you have any allergies?*
  • Have you had any surgery within the past 12 months?*
  • Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?*
  • Do you use recreational drugs?*

  • Service Information

  • Do you want to lose body fat?*
  • Do you want to tighten skin on your body?*
  • Do you want to reduce cellulite?*

  • Butt Cupping Consent Form

  • Vacuum therapy is a noninvasive massaging technique that utilizes a mechanical device equipped with vacuum-suctioncups in order to increase lymphatic circulation and break down fatty deposits and cellulite and visibly lift and tighten your skin. vacuum therapy is a non-invasive treatment with no downtime, however. as with any treatment there a re certain benefits and risks. Please read and initial each of the statements below:*
    • Body Aches
    • Irritation
    • Bruising 
    • Mild discomfort
    • Discoloration 
    • Redness
    • Headache 
    • Nausea
  • *

  • Consents

  • I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit. publish, distribute and make use of any and all pictures. video, and/or audio is 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 networking 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 or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions. and causes of action which I. my heirs. representatives. executors. or any other persons may make while acting on my behalf or on behalf of my estate.

  • By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

     

    By signing below, I agree to the following:
    I have completed t his 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 cond ition(s) that would make the requested treatment unsuitable. I will inform the technician of any d iscomfort 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.

     

    I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries. losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

  • Should be Empty: