Client Intake Form

I confirm that all information given in this form is true, complete, and accurate. I released this organization for any responsibility in case of accident, illness, or injury. I acknowledge that no assurance was offered about the outcome.

1. Cancellation/No Show Policy for Appointment 

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. If an appointment is not canceled atleast 24 hours in advance, forfeit my session.

2. Scheduled Appointment

We understand that delays can happen however, we must keep the other patients and doctor on time. If a patient is 15 minutes past their scheduled time, we will have to reschedule/cancel the appointment.

3. Reservation Policy

Sessions will only be confirmed and allowed up to the amount of pre-paid sessions. All sales are final and non-refundable. We reserve the right to terminate any client’s session, package, or contract, without refunding any monies if the client has broken any terms or policies. All purchases are final, non-refundable, and non-transferable.

* I understand if I have purchased and pre-paid for a first-time customer promotion, that I may not use or purchase another first-time promotion without consent.

This form seeks for the consent for photographs to be taken by a 635 Melt or Webber Chiropractic Sports Clinic representative.

By signing this form, the client affirms in understanding that the the images may be used for different purposes indicated hereunder.

By consenting to the release of images, you agree that you will not receive any form of compensation in cash or in kind.

You likewise understand that your name will not be included in the images. Nonetheless, it is still possible that someone may still recognize you.

Your refusal to consent to the release of your photographs will not, in any way affect the care you will receive; You may rescind your authorization to the release of the photographs by writing us a request.

I understand that 635 Melt staff are not licensed physicians and are unable to cure, diagnose, mitigate, prevent, or treat conditions. Services provided by the staff are for aesthetic purposes, increased circulation, and pain reduction. Light therapy should not be used as a replacement for medical treatment from a licensed physician or other healthcare provider. I have been informed that light therapy is generally safe. While side effects are not common, if they do occur, they're usually mild and short lasting. They may include:

I have been informed of the potential risks and side effects of LED Light therapy including but not limited to redness, swelling, heat sensitivity/burn, pain, increase bowel movements and increased urination.  Hyper- or Hypo- Pigmentation is possible and treated area could take 3-6 months to heal. Compliance with recommended aftercare guidelines is crucial for healing, prevention of scarring and hyperpigmentation. The risks, potential damages and adverse side effects have been explained to me and I fully understand them.

LED light therapy is the process in which certain colors of light are used to trigger naturally occurring physiological processes in the body, including cellular healing and nitric oxide release. Clinical studies show nitric oxide can help increase and support basic functions in nearly every part of the body including, but not limited to, increased circulation, stimulated collagen production, increased lymphatic system activity, and decreased nervous excitability. LED light therapy and cold laser are a non-invasive, non-abrasive, and safe for all ages.

I understand that this is a strictly voluntary cosmetic procedure. No treatment is necessary or required and the 635 Melt LED therapy has been chosen by myself (the client).

I understand that a minimum of 9 - 12 treatments is required to achieve results at an average BMI of 25 to 30. A BMI of over 30 (which is considered in the obese range) requires a specific strategy moving forward with the minimum recommendation of 24 + treatments. Each body is different and may require more or less treatments depending on the client’s diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.

I know that if after the treatment program I gain weight, the results of the Red-Light Therapy may be reversed.

I understand that no guarantee has been given as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the Red-Light therapy or cold laser procedure I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion.

I duly authorize technicians to perform the procedure for the purpose of body contouring, lymphatic drainage, improvement of cellulite and skin tightening. I am aware that clinical results may vary depending on individual factors, medical history, patient compliance with pre/post treatment instructions, and individual response to treatment. If I do not make an effort to address my diet and exercise, the results achieved may not be retained.

I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing this informed consent, I grant authority to perform the described treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. Cosmetic indications for these procedures include but are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. Increased redness to the area for up to 12 hours may be experienced (although this is unlikely). Normal activities may be resumed following the treatment.

This agreement is made upon the express condition that 635 Melt, Webber Chiropractic Sports Clinic, and device manufacturers shall be free from all liabilities and claims for damages and/or suits for or by reason of any injury, or death to any person or property of the client while in or upon said premises of services given or any part thereof during sessions of this agreement in connection herewith, and the client hereby agrees to hold harmless 635 Melt, Webber Chiropractic Sports Clinic, and device manufacturers from all liabilities, charges, expenses and costs on account of or by reason of any such injuries, deaths, liabilities, claims, suits, damages, or losses however occurring out of each session. 

No client information will be disclosed to anyone outside of the demonstration without written consent from the client, unless required by law.