Body Contouring Intake Form

Body Contouring Intake Form
Client's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address
example@example.com
Phone Number*
Address

Street Address

Apartment or Suite Number

CityState

Zip Code
Emergency Contact

First NameLast Name
Emergency Contact's Phone Number
Medical Conditions
Are you under the care of a physician?*

YesNo
Please select if you have experienced or are experiencing the following conditions:

CancerHypotensionMetal ImplantsHypertensionPacemaker or DefibrillatorDiabetesClaustrophobiaHeart DiseaseThyroid DisorderHysterectomyHormonal ImbalanceEpilepsy or SeizuresBlush EasilyHIV/AIDSHepatitis A/B/CMigraines/HeadachesDepression/AnxietyPsoriasisRosaceaEczemaBruise EasilySpinal Cord InjuryImmune DisorderLupusKeloid ScarringBlood Clot DisorderSkin DiseaseFibromyalgiaMenopauseCirculation DisorderVaricose VeinsOther
Any known allergies?

ShellfishIodineAspirinTree NutsSunscreenLatexFragranceEssential OilsDairyPollenNoneOther
List any medications or supplements you’re taking:
Ultrasonic Cavitation
For an Ultrasonic Cavitation treatment, select if you have experienced or are experiencing any of the following contraindications:

Diabetes (uncontrolled)Epilepsy or SeizuresPacemaker, Heart Valve Replacement or Severe Heart DiseasePregnantBreastfeedingCurrently menstruatingSevere Liver or Kidney DiseaseCuts, abrasions, or open sores near the treatment areaMetal implants, pins or plates near the treatment areaHIV/AIDSHigh Blood Pressure or Hypertension (uncontrolled)Cancer (all forms)Undergoing Chemotherapy or ImmunotherapyChemical peels and Laser ResurfacingSunburn on/near treatment areaA medical condition that needs Dr. approvalOther
Body Wrap
For a Body Wrap, select if you have experienced or are experiencing any of the following contraindications:

ClaustrophobiaCoronary ConditionsHypertensionPregnantOther
Yoni Steaming
For Yoni Steaming, select if you are experiencing any of the following contraindications:

Currently MenstruatingPregnantOvulating and trying to conceiveInterim menstrual bleedingOther
About Your Body/Skin
If you could improve your body, what would you like to see?
Have you ever received chemical peels, laser services, or microdermabrasion treatments on the service area?

Yes, within the last monthYes, within the last 2-3 monthsNo
Are you taking any medications that are related to cosmetic or skin improvement?
Female Clients
Are you taking birth control?

YesNo
Are you pregnant or breastfeeding?

YesNo
Treatment Policies
Client services and chart information are confidential. Written authorization is required from you to release any information. Your scheduled session is set aside for you. We do not double book appointments. Please reschedule your session if you are more than 15 minutes late. 24-hour cancellation notice is required to avoid being charged for your session. Your card will be charged the full service amount if you cancel your appointent within 24 hours of the appointment or upon no show. You will be draped and at no time will genitalia be exposed with the exception of butt/breast enhancement services. You will have a consultation with your body contouring specialist to discuss your session. After your specialist the has left the room, you may disrobe to your comfort level. Client understands that the body contouring specialist or them may end the session at any time for any reason. Inappropriate behavior is not tolerated and may be prosecuted to the full extent of the law.
Client Agreement
I understand that my data will be strictly confidential. Luxe Glow Lab does not sell, share, or resell information. I acknowledge that my skin might experience temporary irritation, tightness, redness or slight swelling which usually dissipates within 72 hours depending on skin sensitivity. I acknowledge that if I am allergic to one or more ingredients in the products used, I may experience allergic reactions. I acknowledge that this treatment is strictly elective cosmetic procedure and no medical claims have been expressed or implied. To assist with success of Ultrasonic treatment, it is advised that I follow these simple aftercare pointers: Complete 30 minutes of exercise within 12 hours of treatment as well as 3 times a week. Drink 2 liters of water a day. Avoid alcohol, fatty foods and caffeine 24-48 hours post treatment. Follow a well balanced, healthy choice diet, filled with fresh fruits and vegetables. To reserve my appointment, a $25 non-refundable deposit is required. The amount will be applied to the services rendered. Luxe Glow Lab will send an invoice that must be paid before appointment is scheduled. I consent (to the best of my knowledge) that the answers I have given in this form are true and accurate and that I have not withheld any information that may be relevant to my treatment. I give consent for all future treatments. I confirm that if I hold some important information and complications happen, Luxe Glow Lab and its staff will not be liable. I release Luxe Glow Lab and its staff of any liability associated with any injuries and/or current and future conditions resulting from the body contouring procedures or products. I release Luxe Glow Lab and its staff and hold harmless against any claims, expenses, damages, and liabilities. By my electronic signature below, I agree to the treatment policies and client agreement above.
Client Signature*

Clear
Date Signed*

MonthDayYear
Date
Newsletter

Yes, subscribe me to this newsletter.
Should be Empty:

Body Contouring Intake Form

Medical Conditions

Ultrasonic Cavitation

Body Wrap

Yoni Steaming

About Your Body/Skin

Female Clients

Treatment Policies

Client Agreement