YOUR BODY HAVEN - NEW CLIENT CONSENT FORM

CLIENT INFORMATION

** Please review the following questions carefully and answer honestly. Once complete, we’ll be able to book your appointment! **
Full Name*
Date of Birth (birthday)*

MonthDayYear
Current Age*
Sex*

MaleFemale
Full Address*
Email*
Cellphone #*
Occupation*
Emergency Contact:*
Emergency Contact's Cellphone #*
What got you interested in body sculpting?*
Which body area(s) are you looking to target?*
Current business hours are Monday - Friday 9AM to 6PM. What days and times work best for you to come in?*
BEFORE & AFTER PICTURES WILL BE TAKEN TO TRACK YOUR PROGRESS. DO YOU GIVE PERMISSION FOR PICTURES AND VIDEOS FOR THE PURPOSE OF DOCUMENTATION, POTENTIAL ADVERTISING AND PROMOTIONAL PURPOSES? (**YOUR IDENTITY/NAME WILL NOT BE SHOWN!**)*

YESNO
Print Full Name*
Client Signature*

Clear
Date*

MonthDayYear
CLIENT MEDICAL HISTORY
DISCLAIMER: The following may determine whether you are an ideal candidate for body sculpting / body contouring.

Use of Accutane (Isotretinoin) within the last six months, active infection or impaired immune system (i.e., HIV / AIDS), actively trying to become pregnant, pregnancy or breastfeeding, anticoagulant use, autoimmune conditions (i.e., Crohn's Disease, Vitiligo, Lupus (SLE), Rheumatoid Arthritis, etc: A letter of clearance from your primary doctor or physician is required. Cancer: Current diagnosis of cancer anywhere in the body or pre-malignant moles in the treatment area, lymphatic impairment - fat mobilization may be hindered which may affect outcomes. Open wound or any active condition such as eczema, rashes, sores or inflamed skin in the treatment area, pacemaker, cardioverters / internal defibrillator or any other implantable electrical device, severe chronic medical conditions (i.e., congestive heart failure, liver failure, kidney failure, renal failure, lymphatic disease, etc.): A letter of clearance from your primary doctor or physician is required.
HAVE YOU HAD BODY SCULPTING PROCEDURES DONE IN THE PAST?*

YESNO
If you answered "Yes", kindly describe the treatments you've done and where:
HAVE YOU HAD ANY MEDICAL PROBLEMS WITHIN THE LAST YEAR?*
HAVE YOU HAD ANY SURGERIES WITHIN THE LAST 2 YEARS? (IF YES, PLEASE INDICATE WHERE ON THE BODY AND IF YOU ARE FULLY HEALED)*
HAVE YOU EVER HAD ANY AESTHETIC PROCEDURES SUCH AS LASER THERAPY, PEELS, ETC?*
HAVE YOU EVER HAD ANY INJECTABLES SUCH AS BOTOX, RESTYLANE, ETC.?*
ARE YOU CURRENTLY ON ANY MEDICATIONS OR SUPPLEMENTS? (IF YES, PLEASE LIST THEM ALL BELOW)*
CLIENT HEALTH HISTORY
DO YOU SMOKE CIGARETTES?*

YESNO
DO YOU CONSUME ALCOHOL (BEER, LIQUOR, WINE)?*

YESNO
DO YOU CONSUME CAFFEINATED/ENERGY DRINKS?*

YESNO
DO YOU HAVE HEARING AIDS, HORMONE PELLETS, PACEMAKER, METAL OR MEDICAL DEVICES IMPLANTED?*

YESNO
If you answered YES, please indicate what it is and where it is located:
ARE YOU CURRENTLY PREGNANT, TRYING TO BECOME PREGNANT OR BREAST-FEEDING?*

YESNO
When was your last menstrual cycle approximately? (Start and End date)*
WHAT IS YOUR CURRENT ACTIVITY LEVEL FOR EXERCISE THROUGHOUT THE WEEK?*

Level 1 (sedentary/none)Level 2 (some physical activity)Level 3 (moderate physical activity)Level 4 (vigorous physical activity)
WHAT ARE YOUR CURRENT LEVELS OF STRESS?*

LowMediumHigh
How many hours of restful sleep do you get each night?*

3-4 hours4-6 hours7-10+ hours
How many ounces of water do you drink daily?*

None16-24 oz.32-40 oz64-80 oz90-128 oz (1 gallon)
PLEASE DESCRIBE what you generally eat throughout a 24 hour day (protein, fruits, veggies, fast food, etc.)*
DO YOU HAVE ANY OF THE FOLLOWING HEALTH CONDITIONS OR RISKS? (**PLEASE READ CAREFULLY & ANSWER HONESTLY BY SELECTING ALL THAT APPLY**)*

ABDOMINAL SURGERYABNORMAL BLEEDINGABNORMAL BRUISINGABNORMAL HAIR GROWTHABNORMAL PERIODSACTIVE COLLAGENANAPHYLAXISAUTOIMMUNE DISORDERCANCER / CHEMOTHERAPYCARDIOVASCULAR DISEASECOLD SORESCHRONIC SKIN DISORDERDIABETES (UNCONTROLLED)EPILEPSYHEART ATTACKSHEP B / HEP CHERPES SIMPLEX VIRUSHIGH BLOOD PRESSURE (UNCONTROLLED)HIGH CHOLESTEROL (UNCONTROLLED)HIV / AIDSHYPERTENSIONKIDNEY DISEASELACTATING / BREAST-FEEDINGLIPOSUCTIONLIVER FAILURELUPUSLYMPHATIC DISORDERLIPOMASLIPEDEMAMETABOLIC DISORDERSMETAL IMPLANTSORGAN TRANSPLANTPACEMAKERPHLEBITIS / BLOOD CLOTSPCOS / POSPREGNANTSEIZURESSLOW HEALING OF CUTS / BRUISESSTROKETHICKENED SCARSTHYROID ISSUES (UNCONTROLLED)USING STEROIDSVASCULAR DISEASE**NONE OF THE ABOVE APPLY TO ME**
PLEASE PROVIDE ANY RELEVANT INFORMATION REGARDING THE ABOVE (INCLUDING ALLERGIES, ETC.) IF ANY:
CLIENT CONSENT FORM
YOUR SATISFACTION AND SAFETY IS OUR NUMBER ONE PRIORITY TO ENSURE YOUR WELL-BEING BEFORE, DURING AND AFTER YOUR BODY SCULPTING PROCEDURE. PLEASE BE AWARE OF THE FOLLOWING INFORMATION & POSSIBLE RISKS AND INITIAL/SELECT THE BOXES BELOW:
I HAVE CITED ALL CONDITIONS AND CIRCUMSTANCES REGARDING MY HEALTH HISTORY -*

Including medications being taken, and any past reactions to treatments, products or medications that could prohibit or compromise this Body Sculpting treatment. I acknowledge that I am of legal age, and do not experience or have any of the following contraindications listed in this consultation form.
I HAVE BEEN INFORMED OF THE NATURE, RISKS, AND POSSIBLE COMPLICATIONS AND CONSEQUENCES OF BODY SCULPTING -*

I further understand that Body Sculpting should not be treated on those with cardiac issues / thoracic cavity, or be applied over carotid sinus nerves, inflamed/infected/swollen areas of skin and over or near cancerous areas.
I UNDERSTAND THAT ADDITIONAL CONDITIONS COULD OCCUR, WHICH COULD AFFECT MY ABILITY TO TOLERATE THE PROCEDURE -*

In rare cases, discomfort could occur. Risks include but aren’t limited to: redness, tan spots, swelling, pain, heat sensitivity, itchiness, increased bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me, and I fully understand them.
I UNDERSTAND THIS IS AN ELECTIVE, NON-INVASIVE COSMETIC PROCEDURE AND THAT A SERIES OF TREATMENTS IS RECOMMENDED AND REQUIRED TO ACHIEVE DESIRED RESULTS -*

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. I understand and acknowledge that no guarantees have been made to me concerning the results of this procedure. Each body is different and may require more or less treatments depending on the client’s diet, exercise, metabolism and body type.
IN THE EVENT THAT I AM NOT SATISFIED WITH MY TARGETED AREA BODY SCULPTING RESULTS, I AGREE TO IMMEDIATELY CONTACT YOUR BODY HAVEN REGARDING THE ISSUE. I AGREE NOT TO PUBLICLY DEFAME YOUR BODY HAVEN ON ANY ONLINE OR SOCIAL MEDIA NETWORK PRIOR TO CONTACTING THEM. DOING SO IS PROHIBITED AND SUBJECT TO LEGAL ACTION AGAINST A DISPUTE CLAIM.*

I understand that there are no refunds issued for any services or enhancements received from Your Body Haven and that sessions must be used up within 180 days of purchase. In the event that I want to drop out of a package or future sessions, I will be charged at the regular per session rate, not at package rate. If at any point I reschedule an appointment more than once, I understand it may be cancelled completely. I agree to comply with Your Body Haven policies.
I CONSENT THAT THE ANSWERS I HAVE GIVEN REGARDING MY MEDICAL HISTORY ARE CORRECT AND THAT I HAVE NOT WITHHELD ANY INFORMATION THAT MAY BE RELEVANT TO MY PROCEDURE -*

I am sufficiently advised to consent to this procedure. I authorize YOUR BODY HAVEN to perform the procedure for the purpose of body sculpting/contouring, lymphatic drainage, improvement of cellulite and skin tightening. I will not hold YOUR BODY HAVEN responsible in any way for any issues that may arise as a result.
You hereby acknowledge and confirm that you are or have been fully informed as to the nature of the service you have requested and are aware of all risks associated. You have informed YOUR BODY HAVEN of any pre-existing conditions, allergies or sensitivities that may impact your treatment.

We are not liable for any dissatisfaction, discomfort, damage, loss or injury you may incur arising directly or indirectly out of any services provided or any product used. You acknowledge you don't experience Body Sculpting contraindications (which include Pregnancy, Breast Feeding, Recent Cancer, Heart Disease, Pacemaker or Metal Pins or Plates). You hereby release YOUR BODY HAVEN against any adverse reaction sustained as a result of the treatment and confirm that all the information YOU have provided is correct.
** RESERVE YOUR APPOINTMENT:

After you submit this form, our team will reach out with availability for booking your appointment!

Follow @yourbodyhaven on Instagram for fun giveaways/promotions and check out www.yourbodyhaven.com to view our services, client results, reviews, FAQs, policies and more! **
I understand that this is a small business and after booking, ANY cancellation / reschedule within 48 hours of the appointment may require a $50 deposit to be collected.*

Yes, I understand and respect the business policy.
Print Full Name*
Client Signature*

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Date*

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CLIENT INFORMATION

CLIENT MEDICAL HISTORY

CLIENT HEALTH HISTORY

CLIENT CONSENT FORM