Body Contouring Form

Body Contouring Intake Form
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Occupation
Current Medication*
Allergies*
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.
How did you hear about us?

Photograph and Video Release Consent

(Optional: Your face and likeness will be removed)
I First Name Last Name grant Luxe Wellness Boutique the authority to take, edit, alter, copy, publish or distribute and make use of any videos or pictures for content creation and promotion, not limited to newsletters, posters, advertisements, websites, and social networking sites. I realize my images will be of the serviced areas only and no facial recognition or tattoos will be shown without my consent. I wave the right to monetary compensation arising from any use of the images or recording.
I do not consent to photos or videos.

Please read and agree to the statements

I understand it is my responsibility to consult with my physician
Please check all that apply*

I am over 18 years old.I have voluntarily elected to receive body contouring after the nature and purpose of this treatment has been explained to me.I understand that body contouring can be used to reduce fat deposits but is not intended to be a weight loss solution.I understand that the following conditions PREVENT me from having this treatment currently and verify that none of the following conditions apply to me at this time, Cardiac issues Cancer, Infected, inflamed, or swollen skin. Metallic implant (pacemaker),Pregnant/LactatingI recognize there are no guaranteed resultsI acknowledge these treatments my result in swelling, redness, bruising, irritation, increased heart rate or skin irritation. I will report any of these in a timely manner.I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.I have, to the best of my knowledge, given an accurate account of my medical history,including all known allergies or prescription drugs or produc ts I am currently ingesting or usingtopically.
I have more questions and concerns about services and need a mini consultation. (If no, I will call to book or book through the booking site.)*
I Will reach out within 72 hours.
Release Statement: I acknowledge that Luxe Wellness Boutique LLC and all staff members are not medical doctors. I understand staff members may provide nutritional and other health related information to help me maintain my best health. ALL SUGGESTIONS are designed to help me move forward and are not meant to diagnose, claim, treat, or cure any diseases.

I have read this consent and understand it. I am not a minor (under 18).
I have read and understand the refund and cancellation policy.
Should be Empty:

Body Contouring Intake Form

Please read and agree to the statements

Photograph and Video Release Consent

Please read and agree to the statements