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Body Wrap Consulation Waiver 

Consent for treatment:

I give permission for The Primping Place to treat me today. I will disclose any allergies and current medical conditions in this waiver. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service. The FIT Body Wrap trx is an hour long. Its purpose is to encourage sweating to detox, lose weight, improve cellulite & more. The tempurature can be turned down at any time if it gets too warm for your comfort, however please understand it is best to try to leave it on the warmest setting for best results. 


First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Third Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Fourth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Fifth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Sixth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Seventh Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Eighth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Ninth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Tenth Participant's Name

First Name*

Middle Name

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

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Do you have any known allergies? Latex, aspirin, shellfish, iodine, food, etc... If so please list:
Are you currently being treated by a physician for any conditions?*
No
Yes

If you answered yes to the question above please specify:

Please list any medications/vitamins that you are taking:
Are you pregnant or nursing?*
No
Yes

Please list any surgeries within the past year if applicable:
Have you had Cancer, Diabetes or Lymph Node Surgery?*
No
Yes
Do you have any metal implants or pacemaker?*
No
Yes
Do you use a tanning bed?*
No
Yes
Do you use sunscreen daily?*
No
Yes
Do you have trouble lying down for long periods of time?*
No
Yes
Are you claustrophobic?*
No
Yes

How many 8oz glasses of water do you drink daily?

How many cups of coffee/other caffeine?
Do you regularly exercise?*
No
Yes

If yes to regular exercise, then how often?

On a scale of 1-10, how would you rate your stress level today? *

What would you like to accomplish with your treatment today? *
Do you currently cleanse your skin morning and night?*
No
Yes

Please list any cleansers, toners, exfoliants, masques, serums, moisturizers or other topicals that you apply daily:
Do you burn easily in the sun?*
No
Yes
Do you get an oily shine throughout the day?*
No
Yes
Would you consider your skin oily, dry, normal, or sensitive?*
Oily
Dry
Normal
Sensitive

Do you have any concerns or questions not listed?

When was your last chemical peel or skin resurfacing treatment?

Consent for treatment:

I give permission for The Primping Place to treat me today. I have disclosed any allergies and current medical conditions. I release any liabilities that may arise during or after as a consequence of my treatment. If my treatments are ongoing, I will disclose any new allergies, medical conditions or medications at the time of my service.

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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