Kuerpo™ Body Sculpting Intake & Consent

Kuerpo™ Body Sculpting Intake & Consent
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact Name
Emergency Contact Phone
What are your goals?

Inch Loss/ ContouringSkin Tightening/ FirmnessCellulite Appearance and reductionPostpartum RecoveryLymphatic Drainage/ Detox SupportMuscle Relaxation / Pain ReliefMaintenance/ General Sculpting
Areas of Concern

AbdomenWaist/ FlanksBackArmsThighsButtocksOther
Health History

Pregnant or breastfeedingPacemaker or implanted medical deviceCancer (current or within 5 years)Epilepsy or seizuresHeart disease or circulatory issuesDiabetes (Type I or II)Autoimmune disorderBlood clotting disorderLiver or kidney diseaseHernia in treatment areaMetal implants in treatment areaRecent surgery (within 6 months)Skin infections, rashes, open woundsSevere varicose veinsUncontrolled high blood pressure
If you checked any above, please explain.
Medications & Lifestyle

Blood thinnersAnti-inflammatory medicationsHormonal medicationsWeight-loss medicationsSupplements affecting circulation or fat metabolism
List current medications or supplements.
Daily water intake

LowModerateHigh
Exercise frequency

1–2x per week3–4x per week5+ times per week
Educational Statement

Body sculpting services at Kuerpo™ are non-invasive wellness treatments designed to support the appearance of inch reduction, skin firmness, and lymphatic movement. These services are not medical treatments, weight-loss programs, or surgical procedures.
Initals in Acknowledgment *
Results Disclaimer

I understand results vary by individual and depend on factors such as hydration, metabolism, lifestyle, and adherence to aftercare. Results may be subtle and progressive, and no specific outcome is guaranteed.
Initals in Acknowledgment *
Normal Reactions

I understand normal post-treatment responses may include temporary redness, warmth, tenderness, mild swelling, soreness, or increased urination.
Initals in Acknowledgment *
AFTERCARE RESPONSIBILITY

I acknowledge that proper hydration, movement, and following aftercare instructions are my responsibility and directly affect my results. Failure to follow recommendations may limit or prevent visible outcomes.
Initals in Acknowledgment *
Photography & Media Consent

I understand that Kuerpo™ may take photographs and/or videos before, during, and after my treatment for the purposes of treatment documentation, progress tracking, and quality assurance.

I understand that these images may also be used for educational, marketing, or promotional purposes (including social media, website, and advertising)

Identifying features will be censored to protect the identity of our clients.
INITIALS IN ACKNOWLEDGEMENT *
SCOPE OF SERVICES

I understand Kuerpo™ practitioners are not medical professionals and do not diagnose or treat medical conditions. I agree to consult a licensed healthcare provider for medical concerns.
INITIALS IN ACKNOWLEDGEMENT *
NO GUARANTEE / NO REFUNDS

I understand that results are not guaranteed and that no refunds are provided for completed services, sessions, packages, or memberships once rendered.
RELEASE OF LIABILITY

I voluntarily consent to receive body sculpting and related wellness services provided by Kuerpo™. I release and hold harmless Kuerpo™, its owners, practitioners, and affiliates from any liability arising from my participation, except in cases of gross negligence.
INITIALS IN ACKNOWLEDGEMENT *
Medical Disclosure & Client Responsibility

I affirm that I have answered all medical history and health-related questions on this form honestly, completely, and to the best of my knowledge. I understand that withholding, omitting, or providing inaccurate information regarding my health, medical conditions, medications, or contraindications may increase the risk of adverse reactions or complications.

I acknowledge that Kuerpo™ relies on the information I provide to determine my eligibility for services. I understand and agree that Kuerpo™, its owners, practitioners, and affiliates are not responsible or liable for any complications, adverse reactions, or outcomes resulting from undisclosed, omitted, or inaccurate medical information provided by me.
INITIALS IN ACKNOWLEDGEMENT *
Client Signature*

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