Loading...

Body Contouring Treatment Consent Form

This is an informed consent document which has been prepared to help inform you about light and infrared based treatment procedures for body countouring and fat reduction. 

Please read this information carefully and completely before you sign and consent to receive the treatment at Ease Medspa & Wellness Group.  

Pre & Post Care Instruction:

Before Treatment:

  • Do not eat a heavy meal in the 2 to 4 hours Before and After each treatment.
  • Do not fasting before treatment – body will go into starvation mode.
  • Avoid alcohol, coffee, or carbonated drinks 2 to 4 hours Before and After treatments.
  • Drink 6-8 glasses of water on the day of treatment. Good hydration provides a healthy lymphatic system.
  • Do not put any creams, gels or other formulas prior to the treatment, it will diminish the light.
  • Wear comfortable clothes. 
  • Consider treatments around menstruation.
  • Lipo-Light and Infrared Slimming Bodywrap are safe and totally non-invasive treatment. Anyone with a history of cancer, HIV + and teenagers under 18 must get clearance from their medical provider.
  • Anyone with Pregnancy, lymphoma or leukemia, epilepsy, photosensitivity disorder, pacemaker, Thyroid Gland dysfunction, Uncontrolled Hypertension, Uncontrolled diabetes, Radiation treatments, Kdney and Liver Disease, Cardiac Arrythmia’s, Immuno- Suppressed may not receive the treatment.

After Treatment:

  • You may continue to burn fat over the next 24-48 hours.
  • Body contouring treatments combine with exercise are Essential! Exercise daily for 30 minutes or longer will enhance the results.
  • Continue drinking water to help the lymphatic drainage.  
  • Start a sensible nutrition plan with plenty raw and super food.
  • Complete the treatment plan: based on the clinical data, the best and long lasting result will be achieved with a series of treatment.

Acknowledgment:

  • 24-hour Cancellation & Rescheduling Policy: I do understand that my appointment is one-on-one service and it is my responsibility to Call, Email or send Message 24 hours prior to my appointment if I need to Reschedule or Cancel my designated appointments. 
  • No Show Policy: I understand that if I miss my appointment without canceling 24-hours in advance, it will be recorded as a “No Show” in my file. 
  • I do understand the 24-hour policy, and I agree to pay the appropriate fee of $30 if I fail to cancel or reschedule 24 hour in advance. The same rule applies to No Show appointment.
  • No Refund: I do understand all sales are final and not refundable. 
  • No Guarantee: I understand that there is No guarantee can be made concerning the results of the treatment. Optimal results are achieved with a series of treatments, and the total number of treatments will vary between individuals. 
  • I acknowledge that Pre & Post-procedure instructions have been provided to me by Ease Medspa & Wellness, and I understand it is very important to follow these instructions and obtain the maximum results. 
  • I understand that the service requested to be performed on me by Ease Medspa & Wellness Group is purely elective.
  • I confirm that I am Not pregnant at this time, and I will inform Ease Medspa Wellness if I become pregnant in the future so I can stop all light based treatments. 

 

By signing this consent form, I understand it is valid for all of my future treatments at Ease Medspa & Wellness Group, and I do understand it is my responsibility to inform the staff if any medical or prescription changes. 

  • I confirm that my questions regarding the treatment procedures including the benefits and potential risks, possible complications associated with the treatments have been answered satisfactorily.
  • I confirm that I have understood the treatment and the above medical informaton I have given is accurate.
  • I am willing to proceed without confirmation from my own primary physician or medical consultant. It is my responsibility and not that Ease Medspa & Wellness Group and the practitioner to consult my primary physician if necessary.
  •  I, and any of my heirs, executors, representatives or assigns hereby release Ease Medspa & Wellness Group Inc. from any and all injuries, actions, causes of action, suits, damages, judgments, claims, and demands whatsoever, in law or equity, while on the premises during the treatments performed by any practitioners of Ease Medspa & Wellness Group Inc.

Dated: January 26, 2021

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
Parent or Guardian's Email Address

Email*

Confirm Email*
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.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Client Questionnaire

Do you workout/exercise?*
No
Yes
Have you ever had Lipo-Light or Infrared Bodywrap treatment?*
No
Yes
If Yes, please indicate what treatment(s) you have done before*
Please indicate if you have or had any of the following:*
Kidney / Liver disease
Heart disease / Pacemaker
Cancer
Currently Pregnant
Medical edema
Auto immune disease
Any metal pins or plates
Thyroid problems
Urinary infection
Diabetes
Skin disease
None of the above
Any condition listed above already being treated by a medical practitioner.*
No
Yes
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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!