BODY CONTOUR CONSENT FORM

Date*

Date

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

I understand that these treatments are not recommended if I am pregnant, breastfeeding, have a lymphatic disorder, acute illness, metal implants, pacemaker, or are currently being treated for active cancer.*

I understand that neither office personnel of LUX BODY LAB nor this agreement provides a guarantee of results. This agreement deals solely with the services to be rendered and the fees to be paid for the care as provided. Your payment obligation is not contingent upon the outcome of services.*

I certify that the information on my intake form is true, and acknowledge that any misrepresentation of my health history may result in injury or death. If any of the information about me or my health history is false, misleading, or undisclosed, I agree that LUX BODY LAB will not be held liable.*

I agree to inform and notify immediately LUX BODY LAB should any information regarding my health history past and present change.*

I agree that I have answered all the questions about myself and health history to the best of my abilities and knowledge.*

Should I decide to add a treatment, that treatment will be considered an additional and separate treatment.*

There are no refunds if I am responding to a treatment and decide to stop treatments.*

I understand and acknowledge that payments for the above services are non- refundable.*

I further agree to provide LUX BODY LAB 24 hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only.*

By my signature below, I certify that I have read and understand the contents of this consent form.*

SIGNATURE*

BODY CONTOUR CONSENT FORM

CLIENT HEALTH | MEDICAL HISTORY