Massage and Body Contouring Consent Form

Massage and Body Contouring Consent Form

The Body Image
Name

First NameLast Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Person

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Medical Conditions
Service Interested In
How did you hear about us?
What are your goals for this session?
Are you currently taking any medications? If yes, please list them below.

Check all that apply

Acknowledgment
Liability Waiver
I release The Body Image of any liabilities such as personal injury and/or damage.
By typing my name below, I acknowledge that I have read and understood this form, and I authorize the services described.
Type your name
Date Signed

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Medical Conditions