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Pure Wax & Beaute Bar
704-910-3069 

 

Non-Invasive Butt Lift/Breast Lift Release Form

Disclosure. This treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depend on the amount of work needed. Actual results vary from person to person and Pure Wax & Beaute Bar(Pure Aesthetics & Beauty Bar LLC) does not guarantee any specific result. The Non-Invasive Butt lift/Breast Lift treatment carries with it possible health complications and consequences, which include but might not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defect, miscarriage, thyroid damage, damage to the ovaries, lactation complications, hyper-triglyceridemia, hyper-cholesterolemia, pancreatitis, infection, scarring and/or allergic reaction to any products used, excessive thirst, dehydration, nausea. Non- Invasive Butt Lift/Breast Lift involves restoring and increasing the area volume with your own fat using a vacuum therapy. The vacuum therapy uses ultrasound waves that lifts, stimulates the muscles and mobilizes the fat permanently. It is a non-invasive technique that promotes natural lifting and tightening of the skin beneath the surface. The treatment uses ultrasound waves to target the deepest layers of skin and stimulate collagen growth. The Non-Invasive Butt lift/Breast Lift treatment includes, but is not limited to, the use of high-power low-frequency ultrasound cavitation which uses 25-40KHz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro-bubbles that increase the pressure around the adipocyte and force it to implode, thus breaking down the adipocyte's cell membrane. Radio Frequency treatments use radio frequency and heat to tighten skin.

After Care. After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.

Before, During and After Pictures. Before, during and after pictures or videos may be taken to document the treatment. These pictures or videos become Pure Wax & Beaute Bar's(Pure Aesthetics & Beauty Bar LLC) sole property and may only be used for its legitimate business purposes.

Release. I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and forever discharge Pure Wax & Beaute Bar(Pure Aesthetics & Beauty Bar LLC)  (including its officers; members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, causes of action, claims and demands, of whatever character, in law or in equity, whether known or unknown, direct or indirect, asserted or un-asserted, and whether or not on account of myself, Pure Wax & Beaute Bar or other third parties, or in any way arising out of the above described treatment I have requested Pure Wax & Beaute Bar perform. It is the intention of the parties that this agreement binds all parties whose claims may arise out of or relate to the treatment or services provided by Pure Wax & Beaute Bar(Pure Aesthethetics & Beauty Bar LLC) including any spouse or heirs of the client/patient and any children, whether born or unborn. Any legal or equitable claim that may arise from participation in the treatment shall be resolved under North Carolina law.

I agree to indemnify, hold harmless and defend Pure Wax & Beaute Bar(Pure Aesthetics & Beauty Bar LLC) (including its officers, members, owners, employees and agents) against all third-party claims, causes of action, damages, judgments, costs or expenses, including attorneys' fees and other litigation costs, which may in any way arise from the above described treatment I have requested Pure Wax & Beaute Bar(Pure Aesthetics & Beauty Bar LLC) to perform.

Dated: September 26, 2022

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
First Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
Client's 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

Emergency Contact's Name*

Emergency Contact's Phone Number*
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 Information
Medical Background Check if you answer YES to any of these questions:
Are you pregnant or nursing?
Are you epileptic?
Do you have any kind of tumor or cancer?
Do you have any cardiac or vascular disease or condition?
Do you have any acute inflammation?
Do you have a wound that has not healed?
Do you have current or any history of internal bleeding?
Do you have a pacemaker or other electronic device?
Do you have any plastic or bone cement or any large metal implant?
Have you had any abdomen operations?
Do you have any abnormally high or low blood pressure?
Do you have high levels of Triglycerides (hereditary)?
Are you allergic to zinc or nickel?
Are you lactose or gluten insensitive?
Do you have hemophilia?
Do you have melanoma?
Do you have thrombosis and / or thrombophlebitis?
Have you undergone a transplant?
Do you have a Neurological disorder?
Are you being treated with anticoagulants?
Do you have any keloid?
Do you have any kind of heart trouble?
Do you have any current infection?
Do you have any infectious disease or tuberculosis?
Do you have advanced untreated diabetes?
Do you have a communicable disease?
Do you have any type of heart, kidney, liver disease?
Any other medical condition?
Do you have any injections or implants?

If you checked any of the above questions you may not be eligible for treatment. Please explain "Yes* answers here:

Are you presently taking any medications? List:

Are you allergic to any foods or medication? List:

Please explain any other current medical conditions.

Are you taking any vitamins/supplements?:

Are you presently under a physician's care? What for?

Are you taking recreational drugs?

Family or primary treating physician name and phone number:
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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