Loading...

Laser Lipo 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
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical History
Please check all that apply:
Bleeding disorder
Broken Bones
Cancer/Tumor
Diabetes
Dislocations
Fever
Heart Disease
Hernia
Hives/Herpes/Shingles
Hypertension
Infection
Kidney Disease
Liver Disease
Metal Implants
Organ Failure
Pacemaker
Pregnant/Nursing
Skin Disease
Sunburn
Transdermal Drug Delivery System
Transplant
Ulcerated Skin
Unhealed Wounds
Are you currently taking medications?*
Yes
No

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

If yes, please list.
Have you had any surgeries in the past 12 months?*
Yes
No

If yes, please list.

When was the first day of you last menstrual cycle
Service

What areas would you like to address?

Please describe your exercise routine?

Please describe your current dietary habits?

How many ounces of water do you drink a day?
Consent
I understand that laser lipo is a noninvasive procedure that may help liquify fat cells and stimulate the production of collagen which results in firmer, tighter, and smoother skin. I understand that Lipo Laser/LED procedure may have known or unknown complications including but not limited to redness, swelling, heat sensitivity, pain, increased bowel movements, increased urination, increased menstrual flow and flu like symptoms.*
Yes
No
I understand that any medical or cosmetic procedure carries risk, and varied results as to the effectiveness of a particular treatment.*
Yes
No
I have voluntarily elected to receive Laser Lipo after the nature and purpose of this treatment have been explained to me*
Yes
No
I understand that it is recommended that I will need a minimum amount of treatments for Laser Lipo to achieve its desired effect.*
Yes
No
I understand that results do vary and no guarantee is implied or suggested that desired results will be achieved.*
Yes
No
I understand that this treatment should be used in conjunction with a healthy diet and exercise.*
Yes
No
I understand that during treatment there should be no discomfort, and I will feel warmth of the light and tightness of bands/belt.*
Yes
No
I understand that if for any reason during treatment, I feel discomfort due to the warmth of the paddles/belt, I will inform my technician and the paddles/belt will be removed.*
Yes
No
I understand that I should avoid caffeine, sugar, processed food, and dairy after my appointment*
Yes
No
I understand that I should drink plenty of water after my appointment to help flush my body*
Yes
No
I have to the best of my knowledge given an accurate account of my medical history.*
Yes
No
I understand that the following conditions may make me ineligible to receive treatment: Autoimmune disease, Hepatitis C/D, Heart Disease, HIV/AIDS, Cancer, Pacemaker, Pregnant, Thyroid Disease, Liver Disease, or Kidney Disease.*
Yes
No
I understand that while rare, an allergic reaction or adverse reactions may occur and that I do not hold Allure Body and Wellness responsible.*
Yes
No
I have read and completed the consent form and understand the risks and benefits explained.*
Yes
No
I consent to treatment and I assume all responsibility for the risks described above.*
Yes
No

This authorization will remain in effect until revoked by the patient in writing.

Guarantees
I understand that results vary with each individual. There are no guarantees of the results. Additional sessions maybe required and encouraged.*
Yes
No
Photos
Do you give Allure Body and Wellness permission to take before and after pictures during your treatment.*
Yes
No
Do you give Allure Body and Wellness permission to use your pictures taken during your treatment 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.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!