Body Sculpting New Client Intake Form

Any medical or cosmetic procedure carries risk, complications and varied results as to the effectiveness of a particular treatment. The purpose of this document is to make you aware of the nature of procedure and its risks in advanced so that you can decide whether to go forward with any procedures/treatments.

 

PROCEDURES

Initially you will consult with the consultant to determine if you are a candidate for Body Sculpting or other inch loss procedures. During this time you will have the opportunity to ask questions or voice concerns you may have regarding this treatment. If it is determined you are a candidate for any procedure, there will be a few preliminary steps consisting of: initial paperwork, measurements, pre and post treatment photos and suggested course of treatment. It is recommended that a client will need a minimum of 6 or more treatments for the therapy to achieve its desired effect. These treatment should be used in conjunction with a healthy diet and exercise. If you are not currently exercising you should consult a health care professional before beginning an exercise program to determine if your body is physically able.

 

RISK/DISCOMFORT

Our treatments are non-invasive. During treatment there should be no discomfort. If for any reason during treatment that the client feels discomfort due to warmth or any discomfort, treatment will be terminated. Client should report this discomfort to technician immediately. If client chooses to continue through any discomfort, it is at the client's own risk and provider assumes no responsibility. Procedures are recommended for anyone over 18.

 

BENEFITS

The potential benefit of this treatment is body contouring without surgery. Problem areas or excess pockets of fat can be targeted, however the most commonly treated areas are the stomach, hips, flanks, and thighs. In clinical trials patients have averaged 2-5cm lost from there stomach, hips, and thighs. These results do vary and no guarantee is implied or suggested that desired results will be achieved.

 

QUESTIONS

By signing below, you certify that this procedure has been explained to you and your satisfaction. Any further questions can be directed to your therapist.

 

CONSENT

I have reviewed this consent form. My consent and authorization for procedures are strictly voluntary. By signing the informed consent form I grant authority for Ashley Francisco to perform the requested treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction.

Cosmetic indications for these procedures include but are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. You may experience increased redness to the area for up to 12 hours. You will be able to return to normal activities following the treatment. Any photos taken will be used to show the clients progress and may be used in marketing ads.

I have been informed of the potential risks and side effects of all procedures and treatments including but not limited to redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me and I fully understand.

I understand that a minimum of 6 or more treatments may be required to achieve full results. At that point, I will be reevaluated to see if more sessions are needed in order to achieve realistic goals. Each body is different and may require more or less treatments depending on the client's diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.

No guarantee has been given by anyone as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the procedures I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion. The undersigned assumes all responsibility for behavior of self and their clients and agrees to abide by all Rules and Procedures of the property.

I further state that I am of lawful age and legally competent to sign this aforementioned release; I understand the terms of place the highest priority on the client's right to privacy. We do not disclose identifiable information to any third party without your consent. Further, we do not sell, rent, or otherwise allow the unauthorized outside use of personal information such as names, addresses, phone numbers, or e-mail addresses in our database without your permission. Copies of this form and signature will be valid as if original if this document is digitally scanned.

I am over the age of 18 and in apparently healthy condition. I understand the above potential risks and benefits of these services. I understand that injury can be unrelated to the technician, instruction, or equipment.

I agree to NOT hold Ashley Francisco (Cisco Beauty) responsible for any claims or negligence.

I here by grant and authorize Ashley Francisco (Cisco Beauty) the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/ or audio taken of me to be used in and/ or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social media sites and other print or digital communications without payment or any other

This authorization extends to all languages, media, formats, and markets now known and

I will be consulted about the use of the photograph and/ or video recording for any purpose

other than those listed below:

promotional materials; printed and/ or digital advertisements; educational presentations or courses; informational presentations;

online educational courses; educational videos;

There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed. By signing this form I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.