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Release of Liability for Body Contouring and Radio Frequency

 I have voluntarily elected to undergo this treatment/procedure. The nature and purpose of this treatment has been explained to me, along with the risks and hazards involved

I Agree

 

I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications

I Agree

 

I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. I understand that maintaining a balanced diet and excercise program is critical to my results

I Agree

 

In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult Body+ Soul immediately.

I Agree

 

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs,herbal supplements or products I am currently ingesting or using topically. I do not hold Body+Soul or the provider responsible for any skin condition that is present, but was not disclosed at the time of the skin care procedure which may be affected by the treatment performed today


 

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. All my questions have been answered to my satisfaction and I consent to the terms of this agreement


 

 

 

 

 

First Client Name Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

Last Name*
Tenth Client Name Date of Birth*
Client Name Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
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*
Please list ALL medications you are taking- including supplements. Please note that failing to list all medications may result in poor treatment results, or possible injury.

Click to customize text box label *
Body Contouring Contraindications

Do you have any of the following medical conditions?

Epilepsy, Kidney/Renal Failure, Liver Failure, Hypertriglyceridemia and Hypercholesterolemia, or Thyroid conditions.

Are you currently pregnant or nursing?*
No
Yes
Radio Frequency Contraindications
Do you have a current history of skin cancer or any other current condition of cancer or premalignant moles?*
No
Yes
Do you have any diseases which may be stimulated by heat such as recurrent herpes simplex in the treatment area?*
No
Yes
If yes to the above question, have you completed a prophylactic regimen in preparation for today's treatment?*
No
Yes
N/A
Do you have a history of any type of cancer not cleared by your doctor?*
No
Yes
Do you have any permanent makeup or tattoos in the treatment area?*
No
Yes
Do you have an impaired immune system due to immunosuppresive diseases such as HIV, AIDS, or use any immunosuppressive medications?*
No
Yes

If yes to the above question, please explain.

Do you have any poorly controlled endrocrine disorders?*
No
Yes
Do you have any active condition in the treatment area, such as sores, psoriasis, eczema or rash?*
No
Yes
Do you use any medications, herbs, food supplements, or vitamins that are known to induce photosensitivity to light such as Retin A, Accutane, and St. John's Wart?*
No
Yes

If yes, please list below.

Have you had any surgical procedures in the treatment area within the last 3 months or before and is not yet completely healed?*
No
Yes

If yes, please explain.

Have you received any of the following injections in the last 3-4 weeks? Neurotoxin, Natural Fillers or Synthetic Fillers?*
No
Yes

If yes, please explain.

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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