Body Sculpt + Face & Chin Treatment Consent

Waiver of Liability and Consent Form

Ultrasound Cavitation Treatment Agreement
Name

First NameLast Name
Email Address
example@example.com
Date Of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address
Phone Number
Format: (000) 000-0000.
Emergency Contact Name & Phone Number
Emergency Contact Phone
Format: (000) 000-0000.
Ultrasound Cavitation Treatments: Check all that apply
Medical Background Check if you answer YES to any of these questions:
IF YOU ANSWERED "YES" TO ANY OF THESE QUESTIONS ARE NOT BE ELIGIBLE FOR THE TREATMENT
Are you presently taking any medication, vitamins or supplements? List:
Are you allergic to any foods or medication? List:
Are you currently taking any vitamins or supplements? If yes, please list:
Please explain any other current medical conditions:
Are you presently under a physician's care? If yes, what for?
Please list your Primary Care Physician Name and Phone Number:
Are you taking recreational drugs?
How did you hear about Bloom Beauté Studio?
Name of Referral:
Financial & Cancellation Policy- Click to indicate that you have read each statement thoroughly and acknowledge, understand and agree to the following:

Please be advised that payment for all services is due at the time services are rendered. We require full payment for the visit prior to being seen by our cavitation technician. All forms of payment are immediately run through an electronic processing system and immediately deposited into electronic transfer system. In the event this account is referred to an agency for collections or if an electronic check is returned you agree to be responsible for all returned fees including any collections costs, collection's agency and/or attorney's fees
Client Waiver & Release

Initial to indicated that you have read each statement thoroughly and acknowledge, understand and agree to the following:
Your Initials* Disclosure. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits aresubject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Bloom Beauté Studio does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, whichinclude but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to theovaries, lactation complications, hyper-triglyceridemia, hyper- cholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any productsused, excessive thirst, dehydration, nausea. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high-power low-frequencyultrasound cavitation which uses 40KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubblesthat increase the pressure around the adipocyte and force it to implode, thus breaking down adipocyte’s cell membrane.
*   Release. I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility forpersonal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Bloom Beauty Studio LLC and Ashley Alvior from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not on account of myself Bloom Beaute Studio LLC, Ashley Alvior or other third parties, or in any way arising out of the above described treatment I have requested Bloom Beaute Studio LLC and/or Ashley Alvior.
Your Initials*   Arbitration. It is understood that any dispute arising as to malpractice of the eyelash extensions service shall be decided by a neutral arbitrator. Any arbitration proceeding will be governed by Hawai’i arbitration statute, the fees for the arbitrator will be split pro-rata among the parties and each party will be responsible for their own attorneys' fees and costs. Any action to collect fees from the client/patient for the treatments performed brought in any court located in Hawai’i and the prevailing party in such collection action shall be entitled to recover its reasonable attorneys' fees and costs. Filing of any action in any court to collect any fee from the client/patient shall not waive the right to compel arbitration of any malpractice claim.
Recommendations:(Prior to starting your first session and during treatment process)
- Prior to starting your first session and during each 3-day period of treatment, we recommend you drink 2-3 liters of water. Water and hydration is key to this process being effective.
- To maximize the effectiveness of your session, it is best to restrict products that impact lymphatic flow (i.e. caffeine, alcohol and sugar in large amounts) during the process.
- We recommend eating a healthy diet to enhance the process. We recommend exercise to stimulate lymphatic flow. This includes low impact workouts, swimming, jogging and or cycling during this process. Even brisk walking will help.
- We recommend no more than one body area per lymphatic area and maximum of 30 min of ultrasound time for maximum results. Treatments can be done a minimum of 72 hours apartt.
- IF YOUR DIGESTION PROCESS IS IMPEDED IN ANY WAY DURING SESSIONS LET US KNOW (I.E. CONSTIPATION
- Please always discuss with your Physician before beginning any new Health & Diet Program.
- Always inform us if you have a change in health status or experience any unusual symptoms during your program.
- If you should become pregnant during this process please inform us immediately.
- You can have Ultrasonic Cavitation during your Menstrual Cycle but it is recommended to avoid the abdomen as you will not see the same results due to bloating.
- Please inform us immediately if you have a change of health during your program that was not indicated on the intake form.
By signing this agreement, I confirm that am over the age of 18. l understand that the Ultrasound Cavitation procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the Ultrasound Cavitation procedure which is to be performed at my request according to this agreement and Thereby agree to arbitration of any malpractice claim further understand that by signing this agreement,1 surrender certain legal rights.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Signed
Should be Empty:

Waiver of Liability and Consent Form

Client Waiver & Release