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Body Contour Consent


Allure Body and Wellness is commited to providing exceptional service in a timely manner. Unfortunately when a customer cancels without giving notice, it prevents other customers from being served. For those purposes, Allure Body and Wellness has implemented a cancellation policy that will be strictly observed. 

Cancellation and/or rescheduling requests may be submitted by phone or email. We can be reached at (267) 490-7403 or allurebodyandwellness@gmail.com. We respectfully ask that you make contact within 24 hours of your scheduled appointment time. Your $25 deposit is non-refundable and can only be used once towards a rescheduled appointment after cancellation or a no show. If a secondary no call no show were to occur,  you surrender your intial deposit and must pay another deposit to schedule a new appointment.

First Clients Name

First Name*

Last Name*

Phone*
First Clients Date of Birth*
First Clients Signature*
Second Clients Name

First Name*

Last Name*
Second Clients Date of Birth*
Third Clients Name

First Name*

Last Name*
Third Clients Date of Birth*
Fourth Clients Name

First Name*

Last Name*
Fourth Clients Date of Birth*
Fifth Clients Name

First Name*

Last Name*
Fifth Clients Date of Birth*
Sixth Clients Name

First Name*

Last Name*
Sixth Clients Date of Birth*
Seventh Clients Name

First Name*

Last Name*
Seventh Clients Date of Birth*
Eighth Clients Name

First Name*

Last Name*
Eighth Clients Date of Birth*
Ninth Clients Name

First Name*

Last Name*
Ninth Clients Date of Birth*
Tenth Clients Name

First Name*

Last Name*
Tenth Clients Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Select which services you wish to request for your appointment today *
Cavitation
Cellulite Treatment
Laser Lipo
Noninvasive BBL
Post Op Care
RF Skin Tightening
Sauna Detox
Tape Method
Wood Therapy
Vacuum
Slimming Wrap
Medical History
Please select all that apply:
Abdomen Operations
Acute Inflammation
Allergies to Zinc/ Nickle
Anxiety
Arthritis
Arthritis
Asthma
Bleeding Disorder
Broken Bones
Bronchitis
Bursitis
Cancer/ Tumor
Cardiovascular Problems
Chronic Cough
Communicable Disease
Diabetes
Digestive Conditions
Dislocations
Emphysema
Epliepsy
Fever
Fibromyalgia
Frequent Colds
Headaches/ Migraines
Hearing Loss/ Problems
Heart Attacks
Heart Disease
Hemophilia
Hepatitis
Hernia
High/ Low Blood Pressure
HIV/ AIDS
Hives/ Herpes/ Shingles
Hypertension
Infection
Infectious Disease
Insulin Monitor
Jaw Pain (TMJ)
Keloids
Kidney Disease
Liver Disease
Lyme Disease
Metal Implants
Multiple Sclerosis
Neurological Disorder
Numbness/ Tingling
Organ Failure
Osteoporosis
Pacemaker/ Other Electronic Device
Poor Circulation
Pregnant/ Nursing
Psychiatric Disorder
Rashes
Ringing in Ears
Sciatica
Seizures
Sensory Loss/ Change
Shortness of Breath
Sinusitis
Skin Disease
Smoker
Stroke
Sunburn
Tendonitis
Thrombosis or Thrombophlebitis
Transdermal Drug Delivery Service
Transplant(s)
Tuberculosis
Ulcerated Skin
Unhealed Wounds
Vertigo/ Dizziness
Vision Loss/ Problems
Do you have any other medical conditions we should know about?*
Yes
No

If yes, please list:
Are you currently taking any medications (including, but not limited to, blood thinners)?*
Yes
No

If yes, please list:
Do you have any allergies?*
Yes
No

If yes, please list:
Have you had any surgeries in the past 12 months?*
Yes
No

If yes, please list:
Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?*
Yes
No

If yes, please list:
Do you use recreational drugs?*
Yes
No

If yes, please list:

What is the date of the first day of your last menstrual cycle?
Services

What concerns would you like to address today?
Do you want to lose body fat?*
Yes
No

If yes, in what area(s)?
Do you want to tighten your skin?*
Yes
No

If yes, in what area(s)?
Do you want to reduce cellulite?*
Yes
No

If yes, in what area(s)?

Please list your exercise habits:

Please describe your dietary habits:

How many ounces of water do you drink daily?
Treatment Area(s):
Neck
Arms
Waist
Abdomen
Hips
Buttocks
Thighs
Calves
Lower Back
Upper Back
Consent
I certify that I am over the age of 18.*
Yes
No
I have voluntarily elected to receive body contouring services after the nature and purpose has been explained to me.*
Yes
No
I understand that there are no guarantees that the treatment will be effective and to ensure maximum results, multiple treatments will be necessary.*
Yes
No
I understand that this treatment can be used to reduce fat deposits but is not intended to be a weight loss solution.*
Yes
No
I understand that this treatment should be done in conjunction with a healthy diet and exercise.*
Yes
No
I understand that I should avoid caffeine, sugar, processed foods, and dairy after my appointment.*
Yes
No
I understand that I should drink plenty of water after my appointment to help flush my body.*
Yes
No
I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: Body Aches, Bruising, Discoloration, Headache, Irritation, Increased Heart Rate, Mild Discomfort, Redness, Skin Reaction, Swelling, and Nausea.*
Yes
No
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: Acute Illness, Autoimmune Disease, Bell's Palsy, Cardiac Issues, Cancer, Contagious Disease, Fever, Heart Disease, Hepatitis C or D, HIV/AIDS, Infected/ Inflamed/ Swollen Skin, Kidney Disease, Liver Disease, Lymphatic Disorder, Metallic Implant (pacemaker), Pregnant/ Nursing, Thyroid Disease.*
Yes
No
I have been informed of the possible benefits, risks, and complications and I have had the opportunity to ask questions regarding the possible risks and complications.*
Yes
No
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.*
Yes
No

*This authorization will remain in effect until revoked by the patient in writing.*



Photos
Do you give Allure Body and Wellness permission to take before and after pictures during your treatment?*
Yes
No
Do you give Allure Body and Wellness permission to use your pictures taken during your treatment for the purposes of advertising, promoting, and education?*
Yes
No
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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