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Post Op Care Consent

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*

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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Medical History
Please check all that apply:
Anxiety
Bursitis
Chronic Cough
Emphysema
Frequent Colds
Heart Attacks
Hepatitis
High Blood Pressure
Lyme Disease
Osteoporosis
Psychiatric Disorder
Sciatica
Shortness of Breath
Stroke
Vision Loss
Arthritis
Bronchitis
Diabetes
Epilepsy
Headaches/ Migraines
Heart Disease
Herpes
Jaw Pain (TMJ)
Multiple Sclerosis
Pacemaker
Rashes
Seizures
Sinusitis
Tendonitis
Vision Problems
Asthma
Cancer
Digestive Conditions
Fibromyalgia
Hearing Loss
Hemophilia
HIV/ AIDS
Low Blood Pressure
Numbness/ Tingling
Poor Circulation
Ringing in Ears
Sensory Loss/ Change
Smoker
Vertigo/ Dizziness

Other(s):
Are you currently under medical care?*
Yes
No

If yes, who are you seeing and what are you being seen for?
Are you or could you be pregnant?*
Yes
No
Are you currently taking any medications?*
Yes
No

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

If yes, please list:
Do you suffer from chronic pain?*
Yes
No

If yes, please explain:
Have you had surgery?*
Yes
No

If yes, please list surgery and date:
Is this your first time receiving post op care?*
Yes
No

If no, please list the date of your last apppointment?
Are you sensitive to touch or pressure on any areas of your body?*
Yes
No

If yes, where:
How would you describe your stress level (1 being the lowest, 10 being the highest):*
1
2
3
4
5
6
7
8
9
10
Do you exercise regularly?*
Yes
No

Please describe your dietary habits?

How many ounces of water do you drink a day?

What are you goals for this session?
Consent
I give my consent for post op care to be performed by Allure Body and Wellness.*
Yes
No
I understand that there is no implied or stated guarantee of the success of the effectiveness of individual techniques or series of appointments.*
Yes
No
If I experience pain or discomfort during the session, I will immediately inform my practitioner so that pressure/strokes can be adjusted to my level of comfort. I will not hold my practitioner responsible for any pain or discomfort I experience during or after the session.*
Yes
No
I understand that the services offered today are not a substitute for medical care. I understand that my practioner is not qualified to diagnose, prescribe, or treat physical or mental illness.*
Yes
No
I affirm that I have notified the practitioner of all known medical conditions and injuries.*
Yes
No
I agree to inform the practitioner of any changes in my health and medical condition. I understand that there shall be no liability on the practitioner or Allure Body and Wellness part should I forget to do so.*
Yes
No
I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.*
Yes
No

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

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.


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