Body Contouring form

Welcome!

Body Contouring & MLD Massage Intake Form
Thank you for your interest in having your Body Contouring & MLD Massage with us.

PLEASE READ BEFORE FILLING OUT APPLICATION

Booking Process

Below are the service areas and important details required to complete your booking and generate an accurate invoice.

A 50% deposit is required to secure your appointment(s) on the calendar.
Each session lasts 45 minutes and includes the service, travel, and materials.
Parking fees, if applicable, are not included in the session price.

Service Areas Include:
- Doral
- MIA Airport
- Miami Springs
- Coral Gables
- South Miami
- Pinecrest
- Kendall
- Westchester
If your location is outside of the areas listed above, an additional travel fee will apply. This fee may vary based on distance.

Current Package Pricing:

💵 Zelle | 💳 Card

• $140 | $145 (1 Session)

• $390 | $400 (3 Sessions)

• $600 | $615 (5 Sessions)

• $790 | $810 (7 Sessions)

• $1,000 | $1,030 (10 Sessions)

(Travel fee is included)

Afterpay is available. Pricing may vary due to payment processing fees.

Please allow 24 hours to receive back a response, thank you for your patience.

Personal Information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact
Number of Sessions?
Start date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Preferred time
Form of Payment
How did you hear about us?
Social Media Photo/Video Consent
Questions or concerns

Medical History

Rows	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:

Informed Consent

I understand that Body Contouring and Manual Lymphatic Drainage (MLD) services provided by Body Work by Adriana LLC are non-medical, cosmetic/supportive treatments. These services are not intended to diagnose, treat, cure, or prevent any illness or medical condition.

I acknowledge that:
- The purpose of these treatments is to help reduce localized fat deposits, water retention, and cellulite, and to improve skin firmness and contouring.
- Results vary by individual based on body type, lifestyle, diet, exercise, hydration, and adherence to aftercare instructions.
- No specific result, guarantee, warranty, or prediction regarding the outcome has been made to me.
- Body contouring services are NOT a substitute for medical care, weight loss programs, or professional health evaluations, and I am encouraged to consult with my physician prior to treatment if I have any concerns.
Nature of Services

I understand Body Contouring services (including wood therapy, cavitation, radiofrequency, vacuum therapy, sculpting, sauna, and wraps)

Risks, Discomfort & Client Responsibility

I understand temporary redness, bruising, swelling, tenderness, or soreness may occur. Results vary based on body type, lifestyle, and compliance, and multiple sessions may be required. No specific results are guaranteed.

This list does not include all possible reactions and that additional risks may occur. I agree to immediately inform my therapist if I feel pain, discomfort, or any unusual sensation during treatment.

Pre & Post Treatment Responsibilities

I understand that optimal results require proper hydration, a healthy diet, physical activity, and compliance with all after care instructions. I understand that failure to follow recommended aftercare may reduce or delay results.

Results Disclaimer

I understand that results may vary based on body type, metabolism, lifestyle, hydration, and treatment compliance. No specific results or timeframe are guaranteed.

Payment Authorization
How do you plan to pay for services?
Credit Card Authorization

I understand that Body Work by Adriana LLC accepts credit/debit cards, Zelle, cash, Afterpay, and other approved forms of payment.

By signing this Intake Form, I authorize Body Work by Adriana LLC to charge the payment method I provide for authorized services, packages, deposits, membership fees, travel fees (if applicable), cancellation or no-show fees (when permitted under the policies I have agreed to), and any remaining balances that I have authorized.

I understand that this authorization applies only to charges authorized by me and made in accordance with the policies contained in this Intake Form.

I acknowledge that I am responsible for ensuring that my payment method is valid and has sufficient available funds or credit to cover authorized charges.

If my payment method is declined or a balance remains unpaid, I understand that future appointments or services may be delayed or declined until my account is brought current.

I understand that if I use a credit or debit card belonging to another person, the cardholder must complete and sign a separate Third-Party Credit Card Authorization Form before payment can be accepted.

Body Work by Adriana LLC reserves the right to request additional verification from the cardholder before processing any third-party payment and may refuse any payment that cannot be properly verified.

Third Party Payment Authorization
If using another persons card
Cardholders Name

First NameLast Name
Relationship
Package Payment & Commitment Policy

By purchasing a package with Body Work by Adriana LLC, I acknowledge and agree to the following:

• A 50% non-refundable deposit is required at the time of booking to reserve my package and appointment(s).

• The remaining 50% balance is due at or before the first scheduled session, unless otherwise agreed to in writing.

• Package pricing is discounted and offered as a commitment to complete multiple sessions. Individual sessions may not be substituted, separated, or refunded once a package has been purchased.

• Package sessions are non-transferable and may only be used by the original purchaser.

• Unused package sessions must be used within 12 months of the original purchase date unless otherwise approved in writing by Body Work by Adriana LLC.

• If I fail to attend a scheduled appointment or cancel outside of the Cancellation Policy, the applicable cancellation or no-show policy will apply, and the scheduled session may be deducted from my package.

• Packages may not be exchanged for cash, credited toward another person, or transferred to a different service unless approved in writing by Body Work by Adriana LLC.

• I understand that purchasing a package does not guarantee specific results. Results vary based on individual body type, lifestyle, hydration, diet, exercise, metabolism, and compliance with recommended aftercare instructions.

• By purchasing a package, I acknowledge that I have read, understand, and agree to all policies contained within this Intake Form, including the Payment Authorization, Cancellation Policy, and No Refund Policy.

Memberships and promotional packages are subject to their own terms and conditions. Promotional pricing cannot be combined with other discounts or applied retroactively to previous purchases.

No Refund Policy

All services and packages are non-refundable and non-transferable. Dissatisfaction with results does not qualify for a refund.

Cancellation Policy

A 24-hour notice is required to cancel or reschedule. Late cancellations and no-shows will result in applicable fees.

Professional Conduct & Liability Release

I understand this is a professional cosmetic service. Inappropriate behavior will result in immediate termination without refund.

I voluntarily consent to services and release Body Work by Adriana LLC from liability except in cases of gross negligence. This agreement is governed by Florida law.

Media & Recording Policy

Audio or video recording of services is prohibited without consent. Unauthorized recording may result in immediate termination of the session without refund.

Right to Refuse Service

Body Work by Adriana LLC reserves the right to refuse or discontinue services if treatment is determined to be unsafe, medically inappropriate, or if business policies or professional boundaries are violated.

Privacy & Health Information Acknowledgment

I understand that my personal and health information is collected for the purpose of providing safe and appropriate services. My information will be kept confidential and will not be shared without my consent unless required by law.

Medical Disclosure & Acknowledgment

I confirm that:

I have fully and truthfully disclosed my medical history and current health conditions.
I am not pregnant or nursing, unless medically cleared and indicated.
If I have a condition requiring physician oversight (such as heart conditions, liver/kidney disease, uncontrolled hypertension, blood-thinning medications, active infections, cancer, or implanted devices), I have been advised to seek medical clearance from my doctor.
I understand that withholding health information may increase risk and I accept responsibility for that.

Release of Liability & Governing Law

I voluntarily choose to receive body contouring and related wellness services provided by Body Work by Adriana LLC. I acknowledge that I have disclosed all known medical conditions, medications, allergies, and other relevant health information that may affect my treatment.

I understand that Body Work by Adriana LLC provides non-medical cosmetic and wellness services and does not diagnose, treat, cure, or prevent any disease or medical condition. I understand that these services are not a substitute for professional medical care or advice.

I acknowledge that I have been informed of the potential risks, benefits, and limitations of the services I have chosen to receive. I voluntarily assume all known and inherent risks associated with these services.

To the fullest extent permitted by applicable law, I agree to release, waive, and hold harmless Body Work by Adriana LLC, its owner, employees, contractors, and representatives from any claims, liabilities, damages, losses, costs, or expenses arising out of or relating to the services provided, except to the extent caused by gross negligence, reckless misconduct, or intentional wrongdoing.

I understand that no guarantees or warranties have been made regarding the results of any treatment and that individual results will vary.

This Agreement shall be governed by and interpreted in accordance with the laws of the State of Florida. Any legal action or proceeding arising out of or relating to this Agreement or the services provided by Body Work by Adriana LLC shall be brought exclusively in the appropriate state or federal court located in Miami-Dade County, Florida, unless otherwise required by applicable law.
Final Acknowledgment & Consent
By signing below, I certify that I am at least 18 years of age or legally authorized to consent to treatment. I acknowledge that I have carefully read, understood, and voluntarily agree to all policies, disclosures, payment authorizations, waivers, cancellation policies, refund policies, and consents contained in this Intake Form. I understand that my electronic signature has the same legal effect as my handwritten signature.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please provide photo id
Should be Empty:

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