BODY SCULPTING CLIENT INTAKE FORM

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

Email

example@example.com

Occupation

Sex

MF

Emergency Contact Name

How did you hear about us?

Phone Number

Please enter a valid phone number.

Would you like to be added to our email list for specials and discounts?

YesNo

Do you have any chronic medical conditions that we should know about?

YesNo

If yes, please list:

Are you currently taking any medications?

YesNo

If yes, please explain:

Do you have any allergies?

YesNo

If yes, please explain:

Do you have type 1 or type 2 diabetes?

YesNo

Do you have any known kidney or liver disorders?

YesNo

Do you have photosensitivity to sun exposure?

YesNo

Do you currently have cancer?

YesNo

If yes, are you currently on chemotherapy?

YesNo

Have you had cancer in the past 12 months?

YesNo

Do you have any thyroid problems?

YesNo

Do you have high blood pressure?

YesNo

Do you have any cardiovascular conditions?

YesNo

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?

YesNo

If yes, please list:

What concerns would you like addressed today?

Do you want to lose body fat?

YesNo

If yes, from what area

Do you want to tighten skin on your body?

YesNo

If yes, from what area

Do you want to reduce cellulite?

YesNo

If yes, from what area:

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?

(Female clients) Are you currently pregnant or nursing? Yes No When was the first day of your last menstrual cycle?

By signing below, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

I your name , give my consent for body sculpting to be performed by KB Beauty Bar.

Please read and initial each of the statements below:

I certify I am over the age of 18

I have voluntarily elected to receive body sculpting after the nature and purpose of this treatment has been explained to me.

I understand that body sculpting can be used to reduce fat deposits, but is not intended to be a weight loss solution.

I understand that the following conditions preclude me from having this treatment at this time 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/Lactating

I recognize there are no guaranteed results.

I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to:

• Redness

• Swelling

• Irritation

• Skin reaction

• Increased heart rate

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 products I am currently ingesting or using topically.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.

Name

First NameLast Name

Signature

Your appointment is very important. We understand that sometimes schedule adjustments are necessary. Therefore, we respectfully request at least 24 hours’ notice prior to your scheduled appointment time for cancellations or rescheduling of appointments.

Please notify us by e-mail if your cancellation is outside of our normal business hours or you’re unable to reach us by phone at +1-213-556-7936

ANY APPOINTMENTS THAT NEED TO BE CANCELLED / RESCHEDULED MUST BE DONE 24 HOURS OR MORE IN ADVANCE TO APPOINTMENT TIME. ANY APPOINTMENT CANCELLED WITHOUT 24 HOURS NOTICE WILL RESULT IN A CHARGE OF $50. 

ANY NO SHOW OR SAME DAY CANCELLATIONS WILL RESULT IN A CHARGE OF 50% OF THE RESERVED SERVICE AMOUNT.

LATE: YOU HAVE A 10 MINUTE GRACE PERIOD AFTER 10 MINUTES ITS A $15 FEE AFTER 15 MINUTES YOUR APPOINTMENT WILL BE CANCELLED. PLEASE BOOK ACCORDINGLY SO YOU MAY AVOID ANY FEES.

We recognize the time of our clients and therapist is valuable and have implemented this policy for this reason. When you miss an appointment with us, we not only lose your business, but also the potential business of other clients who could have scheduled an appointment for the same time.   

Please remember that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments which result in a cancellation fee. Not receiving an electronic notification of your appointments from us is not sufficient reason to miss an appointment if the original confirmation notification was received timely.

It is mutually understood that if a cancellation is due to circumstances beyond any of our control, such as power outage, unfortunate incidence, illness, or weather that requires you or us to have to cancel or be closed during regular business hours, we will reschedule your existing appointment and no discount or rescheduling fee will apply.

I have read and understand the cancellation policy and agree to abide by the above conditions.

Name

First NameLast Name

Signature

I,   First Name   Last Name   hereby grant and authorize KB Beauty Bar 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 networking 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 or later discovered.
I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy.
Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording.

I hereby hold harmless and release from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.

Name

First NameLast Name

Signature

Due to COVID-19, we are taking extra precautions with each client and have improved our sanitation and disinfecting practices. Please complete the following and sign below.

I confirm that to the best of my knowledge I, nor anyone in my household have any of the following symptoms of COVID-19 listed below, nor have had any of the following symptoms in the past 14 days:

• Fever

• Chills

• Cough

• Shortness of breath • Difficulty breathing • Fatigue

• Muscle aches

• Body aches

• Headache

• New loss of taste or smell • Sore throat

• Congestion or runny nose • Nausea or vomiting • Diarrhea

To the best of my knowledge, neither I nor anyone in my household has been in contact with anyone who has tested positive for COVID-19

I verify that neither I nor anyone in my household has traveled outside of ___________ in the past 14 days.

I understand that the recommends social distancing of at least 6 feet, and this is not possible with the service I am receiving today

By signing below I knowingly and willingly consent to release from any and all liability for the unintentional exposure or harm due to COVID-19.

Name

First NameLast Name

BODY SCULPTING CLIENT INTAKE FORM

Medical History

Informed Consent For Body Sculpting

Cancellation Policy

Photograph and Video Release Form

COVID-19 Liability Release Form