Body Sculpting Consent Form

Body Sculpting Consent Form
Thank you for your interest in having your body sculpting procedure with us. We are with you on your desire to reach your goals for a better body that helps boost your confidence and bring a better lifestyle. We have provided some information that can help you achieve your best results:
1. Drink plenty of water before and after treatment
2. Have a 2-hour fast prior to treatment
3. Perform some physical activity such as exercise
4. Manage your food intake
5. Avoid alcoholic drinks and those with high sugar before and after treatment
Please take note that results may vary for the treatment.

During the treatment, you might feel a warm discomfort. If it's not tolerable, please advise your technician.

At an average, you can expect a reduction from 0.5 inches to as much as 2.0 inches after a treatment.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender

MaleFemale
Date of Birth

MonthDayYear
Date
Age
Contact In Case Of Emergency
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship
Treatment

Cellulite reductionNon-surgical FaceliftUltrasonic CavitationNon-surgical lipoWood Therapy
Areas to be treated

AbdomenArmsButtocksCheeksChinLegsThighs

Medical History

	Yes	No
Are you pregnant or nursing?
Are you immunocompromised?
Do you have any liver or kidney disorders?
Do you have any thyroid gland dysfunction?
Do you have epilepsy?
Do you have cancer or a history of cancer?
Do you have photosensitivity to sun exposure?
Are you taking any drugs that may cause photosensitivity?
Have you undergone an organ transplant?
Do you have any current infections?
Do you have advanced untreated diabetes?
Do you have uncontrolled Hypertension?
Do you have any kind of heart condition?
Do you have hemophilia (blood clotting condition)?
Do you have a keloid scar?
Do you have any infectious disease or tuberculosis?
Do you have a pacemaker?

If you have answered 'Yes' to any of the medical conditions above, we advise you to see your doctor first before undergoing treatment with us. We reserve the right to not begin any treatment should we believe that such treatment may cause risk to our client due to the medical conditions which the client has.
Reminder:

Please make sure that there are no metal instruments that are present on or in your body during the scheduled treatments. If you have any heart or liver problems, uncontrolled high blood pressure, or cancer or undergoing radiology treatments, please see your doctor first. However, if you have a pacemaker, it is unfortunate that we cannot proceed with any of the services that we offer.
CONSENT

I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and physical activity. I understand that non-invasive surgery procedures do not rid the body of visceral fat.

I hereby release and forever discharge the Clinic B's Diverse Styles LLC, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, the Clinic for any liabilities, damages, injuries whether seen or unforeseen.

I understand that any procedure under the Clinic does not constitute medical treatment or cure to any illness.

This form is completely confidntial. Completion of this form for B's Diverse Styles LLC gives a general state of health and assist our specialist in directing a customized course of treatment for you. The information I have provided about my medical history is accurate to the best of my knowledge. I agree to accept responsibility for omissions regarding my failure to disclose any existing or past health conditions.

By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. I have had the opportunity to ask questions and which were answered to me and to my satisfaction. I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence.
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Consent 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 Cavitation 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 vou 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 exereise 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 reels 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 a 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 B's Diverse Styles LLC 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 or light abdominal discomfort 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 B's Diverse Styles owner Brittany Roberson 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 eighteen 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 hold Brittany Roberson not responsible for any claims or negligence.
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Photo & video release Form

I grant and authorize B's Diverse Styles LLC 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 consideration.

This authorization extends to all languages, media, formats, and markets now known and later discovered. 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.
EDUCATIONAL PRESENTATIONS OR COURSES.
INFORMATIONAL PRESENTATIONS.
ONLINE EDUCATIONAL COURSES.
EDUCATIONAL VIDEOS.
SOCIAL MEDIA POSTS.

There is no time limit on the validity of this release, nor is there any geographical 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.
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Should be Empty:

Body Sculpting Consent Form

Photo & video release Form

This authorization extends to all languages, media, formats, and markets now known and later discovered. 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.
EDUCATIONAL PRESENTATIONS OR COURSES.
INFORMATIONAL PRESENTATIONS.
ONLINE EDUCATIONAL COURSES.
EDUCATIONAL VIDEOS.
SOCIAL MEDIA POSTS.

There is no time limit on the validity of this release, nor is there any geographical 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.

Body Sculpting Consent Form

Photo & video release Form

This authorization extends to all languages, media, formats, and markets now known and later discovered. 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. EDUCATIONAL PRESENTATIONS OR COURSES. INFORMATIONAL PRESENTATIONS. ONLINE EDUCATIONAL COURSES. EDUCATIONAL VIDEOS. SOCIAL MEDIA POSTS.

There is no time limit on the validity of this release, nor is there any geographical 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.

This authorization extends to all languages, media, formats, and markets now known and later discovered. 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.
EDUCATIONAL PRESENTATIONS OR COURSES.
INFORMATIONAL PRESENTATIONS.
ONLINE EDUCATIONAL COURSES.
EDUCATIONAL VIDEOS.
SOCIAL MEDIA POSTS.

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.