BODY LAB TREATMENT CONSENT FORM

Body Lab Treatment Consent Form

Date

Name

Date of Birth

Date

Phone Email

Emergency Contact Phone

Procedure

Within the last year, have you been under a dermatologist or other physicians care?

YesNo

If yes, please specify

Within the last 9 months, have you undergone any surgeries?

YesNo

If yes, please specify

Have you had any health problems in the past or present?

YesNo

If yes, please specify

Please list any medications, supplements, vitamins, diuretics, slimming tablets, etc; that you take regularly:

Are you pregnant or trying to become pregnant?

YesNo

Do you have any skin problems pertaining to your face or body?

YesNo

If YES, please specify

Are you currently taking any of the following products? Select all that apply.

CLIENT INTAKE AND RELEASE OF LIABILITY FORM:

Please disclose anything else about your current or previous health history you think would be useful for your provider to be aware of to make this a better experience.

I certify that the treatment/procedure is being given upon my request. I understand that the service provider does not diagnose illness, disease, or any physical or mental disorder, nor do they prescribe medical treatment, or pharmaceuticals. I acknowledge that body services are not a substitue for medical examination or diagnosis, and that it is recommended that I see a primary Health Care provider for that service. I have stated all medical conditions that I am aware of, and will update the service provider of any changes in my health status. I understand that Dolce Vita Aesthetics by law has the right to refuse service on any client at any Sme, if they feel as though their well-being is compromised.

I understand and voluntarily accept the risks associated with the body and/or any other services, including but not limited to: Wood Therapy, CavitaSon + RF Tightening, Laser Lipo, Vacuum BuY Li], Cellulite ReducSon, Fat Dissolving Treatments. Except where prohibited by law; I acknowledge and voluntarily assume the risk of injury, accident or any side effects which may arise from the Treatment/ Procedure performed. I agree Dolce Vita Aesthetics will not be liable for any of the above.

This agreement cannot be amended, except in writing by both parties.

By signing this form, I agree to the above terms and release Dolce Vita AestheScs from any liability whatsoever.

Client Signature

Date

THE FOLLOWING INFORMATION WILL BE USED TO HELP PLAN SAFE & EFFECTIVE BODY SESSIONS EACH TIME YOU VISIT Dolce Vita Aesthetics.

IT IS IMPORTANT THAT YOU ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE.