Body Sculpting Consent Form

Thank you for your interest in having your body sculpting procedure with us. We are with you on your desire to reach your goals for a better body that helps boost your confidence and bring a better lifestyle. We have provided some information that can help you achieve your best results: Drink plenty of water before and after treatment; Have a 2-hour fast prior to treatment; Perform some physical activity such as exercise; Manage your food intake; Avoid alcoholic drinks and those with high sugar before and after treatment; Please take note that results may vary for the treatment. During the treatment, you will feel the contraction of the muscle(s). If it's not tolerable, please advise our technician. You will feel the results on the first treatment. This service is for building muscle and burning fat.

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Gender

MaleFemale

Date of Birth

Date

Treatment

Cellulite reductionNon-surgical Facelift (only applicable to CRYO session)Ultrasonic Cavitation (only for body)

Areas to be treated

Medical History

	Yes	No
Are you pregnant or nursing?
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?
Do you have advanced untreated diabetes?
Do you have uncontrolled Hypertension?
Do you have any kind of heart condition?
Do you have hemophilia (blood clotting condition)?
Do you have a keloid scar?
Do you have any infectious disease or tuberculosis?
Do you have a pacemaker, or another other implant?
Do you have seizures?

If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.

REMINDER:

Please make sure that there are no metal instruments that are present on or in your body during the scheduled treatments. If you have any heart or liver problems, uncontrolled high blood pressure, or cancer or undergoing radiology treatments, please see your doctor first. However, if you have a pacemaker, it is unfortunate that we cannot proceed with any of the services that we offer. Use of electronic devices cannot be used while undergoing this treatment.

BEFORE & AFTER CARE LIST

This is an important decision towards improving your wellness and overall lifestyle. We want to help you reach all your goals. This list will assist you in achieving your best results. It is important to manage your expectations as each individual is different. To get the maximum benefit you will need to engage in an appropriate diet, lifestyle and exercise program in conjunction with your body sculpting treatment protocol.

It is critical that the dietary and lifestyle changes made support the goals of treatment.

A reduced calorie diet and an exercise program to help you burn 350 – 500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing the appropriate healthy lifestyle changes to ensure maximum results. A series of treatment is required to achieve results.

ENSURE YOUR BEST RESULTS

Do not eat 2 to 4 hours prior to treatment(s)
Drink plenty of water before and after every treatment
Consume at least 8-10 glasses of water daily while undergoing treatment(s)
Perform 30 minutes of cardio-exercise directly after every treatment
Manage caloric intake during treatment (excess calories will counteract the treatments)
Abstain from alcoholic beverages for at least 48 hours before and after treatment(s)
Abstain from caffeine at least 24 hours before and after treatment(s).

CONSENT I hereby declare that I am of legal age (18 yrs) and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I understand that non-invasive surgery procedures do not rid the body of visceral fat. I hereby release and forever discharge Bella Day Spa, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, Bella Day Spa for any liabilities, damages, injuries whether seen or unforeseen. I understand that any procedure under Bella Day Spa does not constitute medical treatment or cure to any illness. By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence.

Signature

Date