Forever Young Skin Care Body Sculpting Intake Form

To allow Holistic Body Treatments A Microcurrent/Toning Device

Forever Young body treatments are a form of exercise using low-level electrical current to cause mild muscle contractions. Exercise is not without its risks, and this or any other exercise program may result in injury. They include but are not limited to the risk of injury, aggravation of a pre-existing condition, or adverse effects of overexertion such as muscle strain, abnormal blood pressure, fainting, disorders of heartbeat, etc. If you think you think you have a higher risk, before beginning this or any exercise program, please consult a healthcare provider for appropriate exercise prescription and safety precautions and to make sure you are healthy enough to receive Forever Young holistic body treatments. The treatments and advice here are in no way intended as a substitute for medical consultation. We disclaim any liability from and in connection with this program. As with any exercise program or body treatment, if at any point you feel faint, dizzy, or have any physical discomfort, you should stop immediately and consult a physician.

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DATE

Date

Name *

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Date of Birth

Age

Height

Weight

In case of an emergency contact:

Relationship

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Physician

Specialty

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Please note: This form must be filled in and signed by the client wishing to begin a course of treatment. All treatments will be performed by fully trained operators using the recommended skin care products. All questions are answered truthfully by me and I understand that some conditions may be contraindications to receiving treatments. Forever Young Skin Care will therefor not accept any liability for injury or damages as a result of false information.

Are you currently under a doctor's care?

Yes No

If "yes" please explain:

When was the last time you had a physical examination?

Have you ever had an exercise stress test?

Yes No Don't know

If "yes" what were the results?

Normal Abnormal

Do you take medication on a regular basis?

Yes No

If yes, please list medication and reasons for taking:

Have you been recently hospitalized?

Yes No

If yes please explain:

Do you smoke?

Yes No

Are you pregnant?

Yes No

Do you drink alcohol more than three times a week?

Yes No

Is your stress level high?

Yes No

Are you moderately active on most days of the week?

Yes No

Have your parents or siblings who, prior to age 55 had:

A heart attack? A stroke? High blood pressure?

Do you have:

High blood pressure?

Yes No

High cholesterol?

Yes No

Diabetes?

Yes No

Blood clots or history of blood clots?

Yes No

Peripheral Artery Disease or PAD?

Yes No

Known Heart Disease?

Yes No

Rheumatic heart disease?

Yes No

A heart murmur?

Yes No

Chest pain with exertion?

Yes No

Has your doctor ever said you have a heart condition?

Yes No

Irregular heartbeat or palpitations?

Yes No

Lightheadedness or do you faint?

Yes No

Unusual shortness of breath?

Yes No

Cramping pains in legs or feet?

Yes No

Emphysema?

Yes No

Other metabolic disorders (thyroid, kidney, etc.)?

Yes No

Epilepsy?

Yes No

Asthma?

Yes No

Back pain, upper, middle, lower?

Yes No

If yes, explain:

Other joint pain?

Yes No

If yes, explain:

Muscle pain or an injury?

Yes No

If yes, explain:

Recent operation or illness in the last 6 months?

Yes No

If yes, explain:

Operation or illness in the last year?

Yes No

If yes, explain:

Is there any reason why you should not participate in physical activity?

Yes No

To the best of my knowledge, the above information is true.

Signature

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Date

Contraindications include but are not limited to:

Pacemaker

Epilepsy

History of seizures

Metal Plates

Pins in the Area of Treatment

Diabetes (ok with physician approval)

Cancer (ok with physicians approval)

Recent Surgery

Blood clots or a history of blood clots

PAD or any symptoms of poor circulation

Phlebitis/Thrombosis

Spine problems

Pregnancy

Recent child birth

Any other medical problem that should require a physician's approval letter (attached)

Do not use to treat muscular pain, atrophy, multiple sclerosis, etc. unless you are a licensed physician.

I hear by give Forever Young Skincare, its legal representatives, and assignees in those acting with its permission, the right to copyright and/or use, reuse, and/or publish and re-publish images or video or written testimony of me and any advertising, promotion or public relations involving Forever Young Skin Care, and its products without conversation.

Due to printing, photographing, and reproduction techniques, my image may be slightly distorted in character or form and I do not object to this.

I hear by waive any right to inspect or approve the finished picture, advertising copy, or other matter that may be used in conjunction with an image or video or written testimony of my experience or of me.

I hear by release, discharge, and agree to save Forever Young Skincare, its representatives, assignees, employees, or any person acting with his permission, from and against any liability as a result of any distortion, alteration, or use in the composite form of my picture or video or written testimony.

Name

First Name Last Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email

example@example.com

Date

SIGNATURE (legal guardian's signature and relationship if applicable person is under 21):

Clear

I have read this release before signing and fully understand the content, meaning and impact of this release. *

Yes

This agreement releases Forever Young Skin Care in any person performing the treatments from all liability relating to injuries that may occur during, before or after Forever Young Skin Care treatments. By signing this agreement, I agree to hold forever young skincare and the person performing treatment entirely free from any liability, including financial responsibility for injuries incurred, regardless of whether injuries are caused by negligence.

I also acknowledge the risks involved in body treatments. I have reviewed the contraindications listed on the back of his form and on the medical intake form prior to treatment and I acknowledge that I am in good health and have no health conditions or any other listed contraindications that would prevent me from treatments.

I swear that I am participating voluntarily, and all risks have been made clear to me. Additionally, I do not have any conditions that will increase my likelihood of experiencing injuries while engaging in this activity.

By signing below I forfeit all right to bring a suit against Forever Young Skin Care or any person performing treatment for any reason. I will also make every effort to obey safety precautions as listed in writing and explained to me verbally. I will ask for clarification when needed.

I fully understand and agree to the above terms.

Signature

Clear

Date

Forever Young Skin Care

Health History Form

CONTRAINDICATIONS

Media Release Form

WAIVER OF LIABILITY