Body/Face Sculpting Consent Form

Clients Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Upload a photo of your Photo ID/Driver's/ License/Passport

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number *

Please enter a valid phone number.Format: (000) 000-0000.

Emergency Contact Relationship to Client

Contraindications/Disqualifications

Pregnant (3 months after Birth, 6 months after C Section)
Breastfeeding
HIV/AIDS
Cancer (all forms)
Undergoing chemotherapy or immunetherapy
Immunodeficiency
Lupus
High blood pressure (uncontrolled)
Diabetes (uncontrolled)
Heart problems or diseases
Hypertension (high blood pressure treated with medication)
Kidney damage, disease or problems
Liver damage, diseases or problems
Haemorrhagic disease, trauma or bleeding
Active impanted device such as a pacemaker or defibrillator
Under 18 years of age
Recent surgery (must wait minimum of 6 months)
Recent scars (must wait minimum of 6 months)
Open wounds
Skin diseases (avoid area)
Infection (avoid area)
Antibiotics (wait until course completed)
Inflammation (avoid area)
Varicose veins (avoid area)
Prosthesis/silicone implants (avoid area)
Metal implants/screws (avoid area)
Menstrual period (wait until cycle ends)
Metal contraceptive coil (avoid area)
Depilatory (hair remover) creams (wait 2 weeks)
Areas treated with IPL or laser (wait 2 weeks)
Areas treated with Botox (3 months) or dermal fillers (wait 2 weeks)
Suntan (sun must be avoided the entire duration of the treatment regime)
Numb or insensitive to heat
Rosascea
Transplant Anti-Rejection Drugs
Acute fever
Chronic inflammation (depending on severity of chronic inflammatory conditions - consider that treament will increase inflammation and anti-inflammatory medications reduce the effectiveness of the treatment - please discuss with your doctor first
Conditions that require a doctor's note to confirm the treatment is suitable before treatments can begin:Epilepsy
Thyroid disease
Heart disease
Hypertenion (high blood pressure treated with medication)
Cancer - after 12 months
Body/Face Sculpting Pre-Care Instructions

Avoid eating 1 hour before and after treatment sessions
Avoid heavy meals on treatment days
No fruits or anything with sugar
No alcoholic beverages for 2 days
Drink 2 liters of water 2 hours before your appointment

Body Sculpting Treatment Dress Code

Black undergarments. We recommend wearing light, comfortable clothing such as yoga or workout clothes

Examples: Sports bra, leggings, shorts

Body/Face Sculpting Post-Care Instructions

4-6 hours after treatment, perform 30-45 minutes of cardiovascular exercise in order to create the energy demand that will facilitate metabolism of the fatty acids and glycerol freed from the fat cells
Stagger 2 liters of water intake of 24 hours for 3 days post treatment to help facilitate lymphatic drainage
Avoid fasting or the body will go into "starvation mode" and become more resistant to the release of stored fat
Possible Side Effects

Diarrhea: When fat is successfully broken down, it must exit the body as stool. You may or may not notice an increase in bowel movements. Typically diarrhea is mild and lasts no more than 36 hours
Increased Urination: Loss of water from your tissues is normal following procedures and is a good sign that you are removing fat from your body. Fat enter the blood from the lympathic system, increasing the "thickness" of the blood (oncotic pressure), and pulling water from the tissues to carry the fat to the bowel for removal
Increased Hunger: This is the body's attempt at returning to normal by re-accumulating fat. Do not increase food consumption! Follow a low carb, high protein, high fiber to diet to combat hunger pains
Bruising: Possibly bruising from the treatments
Soreness: From the pressure of the treatment, everyone's body reacts differently
By signing the below I acknowledge that I have read the Pre-Care/Post-Care instructions and Contraindictions/Disqualification List.

Client Signature

Do you have any chronic medical conditions which we should know about?

If yes, please list and explain chronic medical conditions.

Do you have a Thyroid problem?

Do you have any allergies to latex, medications, herbal or natural supplements?

Do you have or have you had any changes in medical history in the last 12 months?

If you answered yes to changes in your medical history, please list the changes and explain.

Do you have Hearing aids, Pacemaker or Hormone Pellets (where) or metal/medical devices implanted?

List all medications, vitamins and supplements you have taken in the last 6 months.

Do you have type 1 or 2 Diabetes?

Do you have or have you had cancer in the last 12 months?

If yes, are you currently on chemotherapy?

Do you have High Blood Pressure or a Cardiovascular condition?

Are you pregnant or nursing?

Current Weight (lbs.)

Height

Mark the checkbox next to any of the below that applies to you.

Do you have a history of colon problems including protruding/distended belly?

If you answered yes to a history of colon problems including protruding/distended belly, please explain.

Have you had any surgeries? *

Please list any surgeries you have had and the month and year of the surgery.

How many glasses of water do you drink per day?

How many cups of coffee do you drink per day?

How often do you consume alcohol in a week?

How often do you consume fast food in a week?

Fast Food Type

How often do you consume soda or carbonated beverages in a week?

How often do you use tobacco in a week?

Do you use Recreational Drugs (narcotics)? *

What is your stress level? *

Iblanks consent to allow the staff members to consult with & evaluate me in order to determine if I am a good candidate for the Non-surgical Body Contouring Program treatments such as lipo cavitation, heat therapy, laser and radio frequency treatments. I understand that photographs and measurements will be taken and kept in my file. Photographs and measurements are required for record keeping and documentation purposes.

I give consent to use images for marketing and or publishing purposes in various media that includes, but is not limited to the internet, media, printed or television.

I confirm that I have completed the form truthfully and to the best of my knowledge/abilities.

Client Signature

Client Signature Date

Date

Body sculpting increases flow of both the lymphatic and circulatory systems, and it also helps with cleaning of the tissues. The main use of body sculpting treatment is inch loss, diminishing of cellulite, and tightening of the skin.

Benefits:
Lose 1-3 inches per treatment with state-of-the-art equipment. Benefits are often immediate, but may be delayed in some people.

For Best Results:
A series of 6-15 body sculpting treatments are recommended per each area, but some individuals may require more treatments to achieve maximum results. There should be at least 3-7 days between each treatment. This is not a weight loss treatment, but an inch loss. The inches will only return if the client goes back to their old habits. Eating the right types of food, proper exercise, and drinking 8 glasses of water per day are always recommended. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar and alcohol for 24 hours after each treatment.

Precautions:
Body sculpting treatments are not recommended if you are pregnant, breast feeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer.

Waiver:
I understand that I am using the Relaxed Fitness Vibration 360/LifePro Waver vibration machine provided at my own risk. Should I sustain an injury while using the equipment, I agree to not hold Bthe service provider responsible.

Acknowledgement:
I understand and acknowledge that payments for the above services are non- refundable. By my signature below, I certify that I have read and understand the contents of this Consent Form for Body Contouring. I further agree to provide 72- hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only. There are no refunds if I am responding to treatment and decide to stop treatments. Should I decide to add an Ultrasound treatment and/or a Radio Frequency treatment, that treatment will be considered an additional and separate treatment. This extra treatment can be paid for separately or deducted from the number of treatments in my Cold Laser package.

Client Signature

Client Signature Date

Date

If there is a need to cancel for any reason, we ask for a 72-hour notice. Please understand that when you do not cancel or show up for an appointment, it is a cost to us. If you cannot provide us with a 72-hour notice, we may impose the following fees:

No Show for Session/Same day cancellation:
*$175.00 charge

I have read and understand the cancellation policy of the service provider and agree to abide by the above conditions.

Client Signature

Client Signature Date

Date

Please read carefully and understand the contents of this form. Ask us if you do not understand. When a client seeks Body Contouring services and when the service provider accepts a client, it is essential that both are seeking and working for the same goals. We expect our clients to take full responsibility for their decisions to participate in any of the services/programs offered by this office. We do not identify, diagnose, or treat ANY condition or disease. We have only one goal: TO OPTIMIZE YOUR BODY'S ABILITY TO FUNCTION NORMALLY AND OPTIMIZE YOUR FAT-BURNING POTENTIAL. By reducing bio-stress levels, we allow the body's inborn self-correcting mechanism to work at maximum efficiency to restore, maintain and promote wellness. We do not identify or diagnose any condition(s) or disease(s). We offer no treatment for any condition(s) or disease(s). We promise no cure from any disease(s) or condition(s). Instead, we facilitate your body's own self-correcting mechanism. It is essential that you speak to your doctor prior to making any decisions about altering any medical regimen you are currently following, changing your diet, taking supplements, or going on an exercise and/or weight loss program. Getting your doctor's approval prior to starting any service/program at our office is critical and solely your responsibility. Should any health condition arise while you are a client, we recommend that you immediately see the appropriate health care provider. Any options that are rendered by the staff and/or head personnel should NEVER be construed as medical advice but merely as opinions. If you like medical advice, please see one of our medical doctors. We will not deal with any medical condition. With your signature below, you understand and voluntarily accept these risks and agree that neither the service provider, its staff, or any of its partners will be liable for any injury to you, including, but not limited to, personal bodily injury, death, mental injury, economic loss or any damage to you, your spouse, or relatives resulting from any act of the service provider, and its staff or anyone else using the facilities and that you acknowledge the inherent risks of the positions, movement, dietary/nutritional programs offered to and done to you at the service provider, with respect to your current or past condition(s). If there is any dispute between you and the service provider, and/or any of its staff, both parties agree to submit it to binding arbitration. We both agree to have a neutral arbitrator preside over any such dispute, not a judge or jury. I, the undersigned, understand and accept the conditions as laid out in the “Terms of Acceptance” above.

Client Signature

Client Signature Date

Date

1. Services to be Provided: The office provides ultrasound, laser, and radio frequency treatments. (Initial Below)

Your Initials

3. Client Cooperation: This Agreement contemplates full Client cooperation in the course of services agreed upon. This cooperation includes Client's agreement to remain active in the recommended program for all body contouring visits. The Client recognizes that compliance with recommended services and service schedule is important and the Client agrees to follow the service plan and the course of treatment agreed upon. The Client understand that lack of cooperation, failure to keep appointments and engaging activities identified by the office as potentially counterproductive to the body may necessitate additional treatments to those otherwise provided for this Agreement. Our office policy requires 72-hour advance notice for appointment cancellation. Failure to do so may result in deduction of pre-paid visits. (Initial Below)

Your Initials

4. Termination: Subject to the provisions of paragraphs 5 and 6 of this Agreement, the Client may discontinue care and terminate this Agreement at any time by written notice to that effect delivered in person, or by mail, to the office. Such “notice of termination” shall discharge the office from all further obligations and/or duty to render care to the client. The office reserves the right to terminate this Agreement in its sole discretion notwithstanding any other terms or provisions of this Agreement. (Initial Below)

Your Initials

5. No Refunds: To encourage commitment and follow-through, the service provider offers no refunds. No refunds will be made on body contour treatments. There will be no exceptions. The prepaid program cannot be altered, shared or transferred, nor can it be combined with any other program. (Initial Below)

Your initials

6. No Guarantee of Results: Client recognizes that neither Office personnel nor this Agreement provides a guarantee of results. The Office makes no guarantee of the extent or longevity of improvement to be expected. This Agreement deals solely with the services to be rendered and the fees to be paid for the care as provided. The Client's payment obligation is not contingent upon the outcome of services. Client's results can be hindered and/or suppressed by the consumption of the following, but are not limited to, alcohol, processed foods including, but not limited to, sugar-based foods and drinks, etc. It is recommended to consult your physician for dietary modification clearance if you have any questions or concerns. (Initial Below)

Your Initials

7. Time Limitation for Services: Client understands that unused visits will expire if not used within 120 days from the date Client starts the treatment unless the Office has been provided with advance notice in writing of leave of absence or other cause of delay. After 24 weeks, all outstanding services/visits will be void. (Initial Below) *

Your Initials

8. Release of Liability: Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company's behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company's gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind. (Initial Below)

Your Initials

9. Your Responsibilities: Keep your appointments. We require 72-hour advance notice to reschedule/cancel an appointment. Follow your program as closely as possible. Report any deviations to the Office staff so that we can help you get back on track. If you have any challenges whatsoever, please share them with us immediately. Remember, it is in both our interests for you to succeed in achieving your goals. If you have any medical conditions, please share this program with your physician immediately. The service provider is not a medical facility and does not make medical decisions.

Your Initials

10. Governing Law: This Agreement shall be governed, construed and interpreted by, through and under the Laws of the State of CA. (Initial Below)

Your Initials

11. Complete Agreement: This Agreement constitutes the complete agreement and understanding between Client and Office and will not be changed or modified in any way unless agreed to by both parties in writing. (Initial Below)

Your Initials

12. I acknowledge and give consent to Oh my Body to use images of my treatment(s) for marketing and, or publishing purposes in various media such as the internet, magazine, printed and or television etc. (Initial Below)

Your Initials

Client

First NameLast Name

THE CLIENT HAS FULLY READ THIS AGREEMENT AND ANY SUPPLEMENT HERETO, AND UNDERSTANDS AND AGREES TO ABIDE BY ALL OF THE TERMS HEREOF.

Client Signature

Client Signature Date

Date

Please state whether you've experienced/are experiencing the following *

Rows

Yes

No

Fever

Cough

Shortness of Breath

Persistent pain on Chest

Have you traveled internationally within the last 14 days?

Do you have a fever now or have in the past 14-21 days?

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?

Have you been in contact with people being infected, suspected or diagnosed with COVID-19?

ONLY IF YOU ANSWERED YES ABOVE Contact tracing will be conducted for close contacts (any individual within 6 feet of an infected person for at least 15 minutes) of laboratory-confirmed or probable COVID-19 patients. Testing is recommended for all close contacts of confirmed or probable COVID-19 patients.Asymptomatic contacts testing negative should self-quarantine for 14 days from their last exposure (i.e., close encounter with confirmed or probable COVID-19 case) If you have already been tested negative after being in contact with someone positive, please provide your test results belo

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Oh my Body has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that Oh my Body can not guarantee that I will not become infected with the Coronavirus/Covid-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, salon staff, and other salon clients and their families.
I voluntarily seek services provided by Oh my Body and acknowledge that I am increasing my risk to exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.
I attest that:
* I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled internationally within the last 14 days.
* I have not traveled to a highly impacted area within the United States of America in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/Covid-19 and not yet cleared as non contagious by state or local public health authorities.
* I am following all CDC recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19.
I hereby release and agree to hold Oh my Body harmless from, and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses and compensation for damage or loss to myself and/or property that may be caused by any act, or failure to act of the salon, or that may otherwise arise in any way in connection with any services received from Oh my Body. I understand that this release discharges Oh my Body from any liability or claim that I, my heirs, or any personal representatives may have against the salon with respect to any bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received fromOh my Body. This liability waiver and release extends to the salon together with all owners, partners, and employees.

Client Signature

Client Signature Date

Date

Body/Face Sculpting Consent Form

MEDCIAL HISTORY

TYPICAL DAILY FOODS AND DRINK INTAKE

Consent Form

CANCELLATION POLICY

TERMS OF ACCEPTANCE/INFORMED CONSENT

Service Agreement

COVID-19 LIABILITY WAIVER