Body Contouring Client Consent & Intake Form

Post Op Intake and Consent Form

Please Read & Sign
Patient Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Email
example@example.com
Phone Number
Please enter a valid phone number.
Emergency Contact Person

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Surgeon Information
Surgeon Name

First NameLast Name
Surgeons Contact Number
Please enter a valid phone number.
Date of surgery
What type of surgery did you receive or will be receiving?
In what state or country was your surgery performed?
Is your doctor aware and in agreement with lymphatic drainage massage? YES or NO?

YesNo
If your answer is NO, I am aware of procedure and risk and assume all responsibility, I assume all risk for all adverse effects as a result of this treatment.

YesNo
How did you hear about us?

FacebookInstagramYouTubeReferralOther
Who referred you?
Medical Condition

The following information will be used to help plan safe and effective post-op sessions. Please answer the questions to the best of your knowledge.
Please list all medications you are currently taking and reason for prescription:
Do you have a diet plan? If yes, please explain below:
Have you already started post-op care somewhere else?

YesNo
Are you doing regular exercise?

YesNo
Are you using any binders or compressions?

YesNo
Do you have any allergies? Do you have any allergies to Calendula or Arnica?? If yes, please list them below.

Do you have any of the following?

	Yes	No	Remarks
Liver disease
Cardiovascular disease
Kidney disease
Skin disease
Thyroid gland problems
Gastrointestinal problems
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV

Do you feel any pain on any part of your body? If yes, which part?
Acknowledgment
Type a question

I understand that this procedure cannot guarantee 100% expected results.I understand that several treatments might be needed to achieve good results.I allow a Retreat Bx technician to take photographs of my before and after results as proof of the treatment.I allow Retreat Bx to use these photographs for case studies, advertising, and marketing.I was educated that hyper-pigmentation might happen temporarily as a result of treatment.I confirmed that all information in this form is accurate and true to the best of my knowledge.I understand body contouring does not treat medical conditions nor does it claim to cure, relieve, or treat any medical conditions.
I understand Body Contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition.
- Body Contouring should not be used on those with cardiac issues.
- Body Contouring should not be applied across or on the thoracic cavity.
- Body Contouring should not be applied over carotid sinus nerves.
- Body Contouring should not be applied over inflamed, infected, or swollen areas of the skin.
- Body Contouring should not be applied over or near cancerous areas.
I understand that any procedure involves risk.  Risks may include redness, swelling, irritation, skin reaction, or increased heart rate.

I have been honest and forthright about my medical history, and am healthy to use the device.  I am not pregnant, have any metallic implants (including a pacemaker), nor any other disease or condition that may be negatively impacted by the Body Contouring device.

Acknowledgment: I understand each person has a different response to the Body Contouring treatment.  The risks, benefits, and possible results have been explained to me. I have been provided with the opportunity to ask questions and received satisfactory responses.

I voluntarily provide my consent to partake in the Body Contouring treatment. Should any pain or discomfort occur I will immediately notify Retreat Bx staff. I will not hold Retreat Bx, employees, or subcontractors liable for any irritation or effects of having thermal heat, radiofrequency, or ultrasonic waves that will be applied during the Body Contouring therapy process.
Your Signature

Clear
Date Signed

MonthDayYear
Date
Liability Waiver
I understand that this activity might lead to personal injury therefore I release Retreat BX & all employees or contactors to any liabilities like personal injury and damage. I also authorize Retreat Bx to make medical decisions for me if needed and if unable to contact an emergency contact person Retreat Body and Wellness LLC (Retreat BX) works closely with medical professionals to ensure the best treatment and the safety of our clients.
Your Signature

Clear
Date Signed

MonthDayYear
Date
Should be Empty:

Post Op Intake and Consent Form

Patient Information

Surgeon Information

Medical Condition

Acknowledgment

Liability Waiver