Form
Heading
Body Sculpting Consent Form
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
Date
Treatment (Check all that apply)
Abdomen
Arms
Chin
Back (Upper & Lower)
Face
Thighs
Buttocks
Other
Medical Background
Pregnant or Nursing
Cancer
Acute inflammation
Epileptic
Cardiac or vascular problems
Open wound
Internal bleeding
Pacemaker or other electronic device
Plastic or bone cement or any metal implant
Abdomen operations
High or low blood pressure
High levels of triglycerides
Hemophilia
Melanoma
Thrombosis
Undergone a transplant
Neurological disorder
Keloids
Heart problems
Current infection
Untreated diabetes
Communicable disease
Heart, kidney or liver disease
Other
If you checked any of the above questions, please explain or if any not listed need to be noted:
What areas/concerns would you like addressed today?
I certify I am over 18
Yes
I have voluntary elected to receive body sculpting after the nature & purpose of this treatment has been explained to me.
Yes
I understand body sculpting can be used to reduce fat deposits, but not intended to be a weight loss solution.
Yes
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. (Cardiac arrest, cancer, infected or swollen skin, pacemaker, pregnant or nursing)
Yes
I understand and acknowledge there are risks involved such as (Redness, swelling, irritation, skin reaction, increased heart rate)
Yes
I have been informed of possible benefits, risks, and complications, and have had the opportunity to ask questions regarding risks & other possible complications
Yes
I grant & authorize the right to take, edit, alter, copy publish and make use of any and all pictures, video & audio taken of me to be used for any lawful promotional materials. Permission granted to use after I approve.
Yes
Current medications you are taking
Are you taking any recreation drugs?
I have read and understand all information presented to me before signing this consent form.
Yes
I hereby release all related staff from all liabilities associated with the above indicated procedure.
Yes
Cancellation policy: In failure to cancel your appointment before the 48 hour mark will result in your $25 deposit.
I understand the cancellation policies at The Body Bar and consent to my deposit being charged if I fail to give a 48 hour notice.
Signature
Submit
Should be Empty: