Snatched Up Body Sculpting Consent Form

Snatched Up Body Sculpting Consent Form

All Clients must complete a consent form prior to any treatment.
Thank you for your interest in having your body sculpting or facial treatment procedure with us. We are with you on your desire to reach your goals for a better body and skin that helps boost your confidence and bring a better lifestyle. We have provided some information that can help you achieve your best results:
1. Drink at least 1 liter of water before and after treatment
2. Have a 2-hour fast prior to treatment
3. Perform some physical activity such as exercise
4. Manage your food intake
5. Avoid alcoholic drinks and those with high sugar content before and after treatment
Please take note that results may vary for the treatment. Advise your esthetician of any allergies you may have at this time.

During the treatment, you might feel a warm discomfort. If it's not tolerable, please advise our esthetician.

At an average, you can expect a reduction from 0.5 inches to as much as 2.0 inches after a treatment.
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
Marital Status

SingleMarriedWidowedDivorced
Date of Birth

MonthDayYear
Date
Age
Contact In Case Of Emergency
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Occupation
How did you learn about us?
Treatment

Cellulite TreatmentNon-surgical FaceliftUltrasonic CavitationNon-surgical laser lipoEMSculptCryolipolysis (CoolSculpting)Lymphatic Drainage (Pressotherapy)Sauna DetoxBrazilian Butt LiftBreast EnhancementVibrating PlatformHigh Frequency WandRadio Frequency TighteningYeso Therapy (Seaweed detox mask is used)Targeted Cryotherapy (Slimming, Facials, Pain Management)WaxingOther
Areas of concern

AbdomenArmsBackButtocksFlanksCheeksChinLegsNeck/DecolleteThighsFaceOther
Daily water consumption

None1-4 glasses5-8 glassesMore than 8 glasses
How often do you exercise?

NeverDaily2-3 times a weekOnce a week
Medical History: Please check if you are affected by or are currently experiencing any of the following;

AnemiaArthritisBack problemsBroken bonesCirculatory problemsKidney disorderLiver disorderEczemaFever blistersHeadachesHemophiliaHepatitisHIV/AIDSHigh Blood PressureImmune DisorderLupusMetal PinsNervousnessNumbnessPacemakerPsychological disordersRadiation TreatmentsRespiratory diseaseShortness of breathSinus ProblemsSkin diseasesSkin rashSwelling of the hands/feetHyperthyroidismHypothyroidismUlcersVaricose veinsEpilepsyPhotosensitivity/Sensitivity to sun exposureHistory of cancerHypertensionHeart conditionSensitivity to heatSensitivity to coldDiabetesPolycystic Ovary Sindrome (PCOS)Heart conditionTuberculosis

Medical History

	Yes	No	Not Applicable
Are you pregnant or nursing?
Have you undergone an organ transplant?
Allergies: Are you allergic to nuts, seafood, iodine?
Are you using any products containing Retinol, Retin A, Glycolic Acid, Alphahydroxy Acids?
Have you undergone surgery within the past 6 months?
Are you under a physician's care for any condition?
Are you currently taking any antibiotics, medications, vitamins or supplements?
Do you wear contacts?
Do you smoke?
Are you allergic to latex?

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.

If you are allergic to nuts, iodine, shellfish or any fruits or vegetables, please verbally inform your esthetician and list in the remarks below.

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.
Please list any additional information about your medical history not mentioned. Remarks:
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 proeed with any of the services that we offer.
CONSENT

I hereby declare that I am of legal age and I understand that treatments for body sculpting and facials 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 for body sculpting or specific skin care routine in the case of facials and chemical peels. I understand that non-invasive procedures do not rid the body of visceral fat.

I release and forever discharge Snatched Up Body Sculpting, LLC, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, Snatched Up Body Sculpting, LLC for any liabilities, damages, injuries whether seen or unforeseen.

I understand that any procedure under Snatched Up Body Sculpting, LLC does not constitute medical treatment or cure to any illness and that any information provided by the estheticianis for educational purposes only and not a diagnosis. I further understand that the information provided herein is to aid the esthetician in giving the most appropriate and safe treatment available and remains confidential.

I understand pictures may be taken for clinical records. If pictures are used for education or marketing purposes, all identifying marks will be cropped or removed.

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, 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.
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