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Ultrasound Cavitation 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.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Medical History
Please check all that apply:
Abdomen Operations
Acute Inflammation
Allergies to Zinc/Nickel
Cancer/Tumor
Communicable Disease
Diabetes
Epilepsy
Heart Disease
Hemophilia
High Cholesterol
High Triglycerides
High/ Low Blood Pressure
Infection
Infectious Disease
Internal Bleeding
Keloids
Kidney Disease
Liver Disease
Melonoma
Metal Implants
Neurological Disorder
Pacemaker/ Other Electronic Devices
Pregnant/ Nursing
Thrombosis or Thrombophlebitis
Transplant(s)
Tuberculosis
Unhealed Wounds
Do you have any other medical conditions that we should know about?*
Yes
No

If yes, pleased list:
Are you currently taking any medications?*
Yes
No

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

If yes, please list:
Have you had any plastic surgery?*
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:

When was the date of the first day of your last menstrual cycle?
Do you use recreational drugs?*
Yes
No

If yes, please list:
Service Information

What concerns would you like to address today?
Do you want to tighten the skin on your body?*
Yes
No

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

If yes, in what area?

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?
Treatment Area(s), select all that apply:
Neck
Arms
Waist
Abdomen
Hips
Buttocks
Thighs
Calves
Lower Back
Upper Back
Consent
I understand that the ultrasonic cavitation treatment uses 30KHz frequency ultrasound to penetrate the skin and assist your body in breaking down fat cells. Multiple sessions may be required to achieve desired results at an additional cost. Ultrasound Cavitation carries possible health risks and complications including but not limited to kidney failure, liver failure, pacemaker failure, birth defects, miscarriage, thyroid damage, ovary damage, hyper-tryglyceridemia, hyper-cholesterolemia, pancreatitis, infections, scarring, and/or allergic reactions to any products used during the treatment(s). I understand that Allure Body and Wellness is using high-power low-frequency 30KHz machine on me during this service and the machine has a mild ringing noise when using it.*
Yes
No
I give my consent for fat cavitation to be performed by Allure Body and Wellness.*
Yes
No
I have voluntarily elected to receive fat cavitation after the nature and purpose of this treatment has been explained to me.*
Yes
No
I understand that that are no guarantees that the treatment will be effective and that to ensure maximum results, multiple treatments will be necessary.*
Yes
No
I understand that fat cavitation can be used to reduce fat deposits but is not intended to be a weight loss solution.*
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: Cardiac Issues, Cancer, Infected, Inflamed, or Swollen Skin, Metallic Implant (pacemaker), Pregnant/ Lactating.*
Yes
No
I recognize there are no guaranteed results.*
Yes
No
I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: Bruising, Headache, Redness.*
Yes
No
I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible 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, during, and after photos?*
Yes
No
Do you give Allure Body and Wellness permission to use your photos taken during your session 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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