La- Beautiq LLC Body Contouring Consultation Form

1
Name* This field is required.
First Name
Last Name
2
Age* This field is required.
3
Date of Birth* This field is required.
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4
Gender* This field is required.
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5
Email
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7
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8
Emergency Contact Person* This field is required.
First Name
Last Name
9
Emergency Contact Phone Number* This field is required.
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10
How did you hear about us?
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11
Are you pregnant?* This field is required.
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Are you breastfeeding?* This field is required.
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Are you currently taking any medications? If yes, please list them below.* This field is required.
14
Do you have any allergies? If yes, please list them below.* This field is required.
15
Do you have any of the following?* This field is required.
Yes
No
Remarks
Liver disease
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Cardiovascular condition (including high blood pressure)
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Kidney disease
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Skin disease
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Thyroid glad problems
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Gastrointestinal problems
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Cancer
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Immuno-compromised
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Photosensitivity to sun
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Epilepsy
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Diabetes
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Underoing hormonal therapy
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HIV
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Chronic medical conditions we should know about?
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Allergies to latex, medications, herbal or natural supplements
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Hearing aids, Pacemaker or Hormone Pellets (where ) or metal/medical devices implanted
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History of Blood Clots
Row 16, Column 0
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Implanted silicone?
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Liver disease
Cardiovascular condition (including high blood pressure)
Kidney disease
Skin disease
Thyroid glad problems
Gastrointestinal problems
Cancer
Immuno-compromised
Photosensitivity to sun
Epilepsy
Diabetes
Underoing hormonal therapy
HIV
Chronic medical conditions we should know about?
Allergies to latex, medications, herbal or natural supplements
Hearing aids, Pacemaker or Hormone Pellets (where ) or metal/medical devices implanted
History of Blood Clots
Implanted silicone?
Yes
Row 0, Column 0
No
Row 0, Column 1
Remarks
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Remarks
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Remarks
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Remarks
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Remarks
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Remarks
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Remarks
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Remarks
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Remarks
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
Remarks
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
Remarks
Row 10, Column 2
Yes
Row 11, Column 0
No
Row 11, Column 1
Remarks
Row 11, Column 2
Yes
Row 12, Column 0
No
Row 12, Column 1
Remarks
Row 12, Column 2
Yes
Row 13, Column 0
No
Row 13, Column 1
Remarks
Row 13, Column 2
Yes
Row 14, Column 0
No
Row 14, Column 1
Remarks
Row 14, Column 2
Yes
Row 15, Column 0
No
Row 15, Column 1
Remarks
Row 15, Column 2
Yes
Row 16, Column 0
No
Row 16, Column 1
Remarks
Row 16, Column 2
Yes
Row 17, Column 0
No
Row 17, Column 1
Remarks
Row 17, Column 2
1 of 18
16
Type a question
I understand that this procedure cannot guarantee 100% expected results.
I understand that several treatments might be needed to achieve good results.
I allow La-Beautiq LLC to take photographs, videos and measurements of my before and after results as proof of the treatment.
I allow La-Beautiq LLC to use these photographs for case studies, advertising, marketing or educational purposes.
I was educated that hyperpigmentation might happen temporarily as a result of treatment.
I confirmed that all information in this form is accurate and true to the best of my knowledge.
17
Your Signature
Clear
18
Type a question
I understand that I am using a combination ow frequency ultrasound, vacuum radio frequency,fractional focused radio frequency and or wood therapy tools machine at my own risk.
I understand that an evaluation is performed in order to determine if I am a good candidate for the Non-surgical Body Contouring Program.
Should I sustain an injury while using the equipment, I agree to not hold La-Beautiq LLC service provider responsible.
I understand and acknowledge that payments for the above services are non-refundable. By my signature below, I certify that I have read and understand the contents of this Consent Form for Body Contouring.
I further agree to provide at least 48- hour notice of a cancellation or change in appointment time. There are no refunds if I am responding to treatment and decide to stop treatments. Should the service provider wish to use any photos of my progress other than for my personal file, I will sign a separate Photo Release form.
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Date Signed
Date
Month
Day
Year
20
I understand that this activity might lead to personal injury therefore I release La-Beautiq LLc to any liabilities like personal injury and damage. I also authorize La-Beautiq LLC to make medical decisions for me if needed and if unable to contact an emergency contact person.

YOUR RESPONSIBILITIES

1. Keep your appointments. We require 48-hour advance notice to reschedule/cancel an appointment.

2. Follow your program as closely as possible. Report any deviations to the staff so that we can help you get back on track.

3. If you have any challenges whatsoever, please share them with us immediately. Remember, it is in both our interests for you to succeed in achieving your goals.

4. If you have any medical conditions, please share this program with your physician immediately. The service provider is not a medical facility and does not make medical decisions.
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Your Signature
Clear
22
Date Signed
Date
Month
Day
Year
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