DEMOGRAPHICS

 

RECENT SURGICAL HISTORY (Regarding your MOST RECENT SURGERY)

Liposuction:

Abdominoplasty (Tummy Tuck):

 

I understand any pre/post consultation, assessment, and any services rendered is not a substitute for medical examination or diagnosis. It is recommended that I see a physician for any physical ailment that I may have. I understand that the provider does not prescribe medical treatments or pharmaceuticals and does not perform any spinal adjustments. I affirm that I have stated all my known medical conditions and answered all questions honestly. I agree to keep the service provider updated as to any changes in my medical profile and understand that there shall be no liability on the provider and company's part should I fail to do so. I am aware that if I have any serious medical diagnosis, I must provide a physician's written consent prior to services.

Iunderstand that Lymphatic Drainage is intended to improve the functioning of the lymphatic system, reduce swelling and promote comfort and relaxation. The technique uses a gentle approach and due to surgical trauma, some discomfort may be felt, however increased pain is not expected. It is my responsibility, and I agree to immediately notify the provider of any discomfort and pain so they may adjust to my level of comfort. Additionally, Ireserve the right to terminate the session at any time, should it be unbearable. If the provider determines drainage is contraindicated in my current state, they too reserve the right to deny or terminate the session earlier than planned.

I understand that if I am uncomfortable for any reason, I may ask to end the session, and the provider will end the session.

The service provider also has a right to end the session if uncomfortable for any reason. I understand that draping of the genital area and gluteal cleavage will be used at all times during the session for all clients.

I understand the breasts of all female clients will be draped and the provider will not engage in breast massage of female clients unless you, the client, gives written consent before each session involving breast massage.

I understand that because post op care and other body work involves maintained touch and close physical proximity over an extended period of time, there may be an elevated risk of disease transmission, including

By signing this release, I hereby waive and release my provider, technician, ancillary staff and their company from any and all liability, past, present, and future relating to post op care and bodywork services.

 

If there is a need to cancel for any reason, we ask for a 24-hour notice. Late cancels and "No Shows" WILL result in the loss of deposit amount of service, and will be deducted from prepaid service package if applicable.

If there is a need to cancel for any reason, we ask for a 24-hour notice. Late cancels and “No Shows” WILL
result in the loss of deposit amount of service, and will be deducted from prepaid service package if applicable.

Specials, Flash Sales & Promotional Priced Services MUST BE completed within 30 days of purchase date.

Regular Price Services MUST BE completed within 60 days of purchase date.

I herein certify that I am not pregnant or nursing.
I understand that NO GUARANTEES OR WARRANTIES have been made to me regarding the outcome or
any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service
and not desired results from treatments. I have been given the opportunity to ask questions and have received
satisfactory answers to those questions by the treating staff representative.

I acknowledge that I have had a fair opportunity to ask questions about procedures and protocol related to the treatments and the alternatives available. I also acknowledge that my questions have been answered to my
satisfaction.

Finally, I certify that I have read and fully understand the contents of this form and that the disclosures referred
to the above were made prior to my signing the form below.