• BODY CONTOURING CLIENT INTAKE FORM

  •  - -

  • Medical History

  • By signing below, I agree to the following:
    I have completed this 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 condition(s)
    that would make the requested treatment unsuitable. I will inform the technician of any
    discomfort 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.

  • Clear
  •  - -

  • Photograph and Video Release Form

  • I         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 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 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      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.

  • Clear
  •  - -

  • Informed Consent For Body Contouring

  • I         give my consent for body contouring to be performed by      

  • Please read and initial each of the statements below:
    _____ I certify I am over the age of 18.
    _____ I have voluntarily elected to receive body contouring after the nature and purpose of this
    treatment has been explained to me.
    _____ I understand that body contouring can be used to reduce fat deposits, but is not
    intended to be a weight loss solution.
    _____ I understand that the following conditions preclude me from having this treatment at
    this time and verify that none of the following conditions apply to me at this time:
    • Cardiac issues
    • Cancer
    • Infected, inflamed, or swollen skin
    • Metallic implant (pacemaker)
    • Pregnant/Lactating
    _____ I recognize there are no guaranteed results.
    _____ I understand and acknowledge that there are risks involved with the treatment I will be
    receiving including, but not limited to:
    • Redness
    • Swelling
    • Irritation
    • Skin reaction
    • Increased heart rate
    _____ I have been informed of possible benefits, risks, and complications, and I have had the
    opportunity to ask questions regarding these risks and other possible complications.
    _____ I have, to the best of my knowledge, given an accurate account of my medical history,
    including all known allergies or prescription drugs or products I am currently ingesting or using
    topically.
    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 technician responsible for any of my
    conditions that were present, but not disclosed at the time of this procedure, which may be
    affected by the treatment performed today.

  • Clear
  •  - -
  • Should be Empty: