Request for appointment / Services
Post op/ body contouring
Client Information
Name
First Name
Last Name
Age
Date of procedure
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
My surgeon was
blanks
My procedure was
blank
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Data
Do you have any allergies?
If yes, please specify on the field above.
Current medical conditions like Asthma, Diabetes, Heart problems, Kidney problems, epilepsy, scoliosis, communicable disease, etc.?
If yes, please specify on the field above.
Consent and Waiver
I, undersigned, agree with the following statements:
I authorize this spa /center to perform the treatment or necessary procedure for me.
I authorize spa/ center to take pictures for work purposes. I understand my face, tattoos, body parts will not be shown.
I acknowledge that I have consulted a physician before undergoing this treatment. I understand that I should consult my doctor before the procedure.
I understand that this is an alternative treatment and if there are any medical concerns, I need to talk to my physician.
I release this spa/ center or person for any responsibility in case of an accident, illness, or injury.
I acknowledge that by signing this form I have read form thoroughly and agree to all the above.
I acknowledge that all information I provided in this form is true and accurate. I also agree to paying deposit before booking and remaining balance at first day of service.
DEPOSIT & PACKAGES ARE NONREFUNDABLE. IF ANY CASE I DO REFUND YOU WILL BE DEDUCTED NORMAL PRICE OF $120-$140 a session
Take into consideration if you do not follow drs instructions and recommendations of 1)NoSalt etc 2)Wear faja as instructed and so on causing you to develop Seroma ,fibrosis. Fibrosis treatments are $150 each session. By signing I agree to this as well.
Signature of the Client
Date Signed
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: