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VACUUM THERAPY 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*

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:
Bleeding Disorder
Broken Bones
Cancer/Tumor
Cardiovascular Problems
Diabetes
Dislocations
Epilepsy
Fever
Heart Disease
Hernias
Hives/ Herpes/ Shingles
Infection
Infectious Disease
Insulin Monitor
Kidney Disease
Liver Disease
Metal Implants
Organ Failure
Pacemaker/ Other Electronic Device
Pregnant/ Nursing
Skin Disease
Sunburn
Transdermal Drug Delivery System
Transplant(s)
Ulcerated Skin
Unhealed Wounds
Do you have any other medical conditions that we should know about?*
Yes
No

If yes, please list:
Are you currently taking any medications (including, but no limited to, blood thinners)?*
Yes
No

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

If yes, please list:
Have you had any surgery within the past 12 months?*
Yes
No

If yes, please list:
Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets?*
Yes
No

If yes, please list:

When was the first day of your last menstrual cycle?
Do you use recreational drugs?*
Yes
No

If yes, please list:
Service Information

What concerns would you like to address today?
Do you want to lose body fat?*
Yes
No

If yes, from what area?
Do you want to tighten skin on your body?*
Yes
No

If yes, from what area?
Do you want to reduce cellulite?*
Yes
No

If yes, from what area?

Please list your regular exercise habits:

Please describe your current dietary habits:

How many ounces of water do you drink daily?
Consent
I understand that vacuum therapy is a noninvasive procedure that uses vacuum technology to create suction on the body surface to increase lymphatic drainage, help reduce the appearance of cellulite, provide a visible lifting and firming effect and more.*
Yes
No
I have voluntarily elected to receive vacuum therapy after the nature and purpose of this treatment have been explained to me.*
Yes
No
I understand that vacuum therapy can be used to reduce fat deposits and cellulite but is not intended to be a weight loss solution.*
Yes
No
I recognize there are no guaranteed results.*
Yes
No
I understand that vacuum-suction cups will be used during this service. I understand that if I begin to feel uncomfortable, I will immediately inform my practitioner so that they may adjust accordingly.*
Yes
No
I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: Body Aches, Bruising, Discoloration, Headaches, Irritation, Mild Discomfort, Redness, Nausea.*
Yes
No
I understand that I should avoid hot showers, baths, hot tubs, and rigorous activity for 4-6 hours after my appointment.*
Yes
No
I understand that I should avoid caffeine, sugar, processed food and meats, and dairy after my appointment.*
Yes
No
I understand that it is important that I drink plenty of water after my appointment to help flush the toxins from my body.*
Yes
No
I understand that my payments for my service are non-refundable.*
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
I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.*
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, during and after photos?*
Yes
No
Do you give Allure Body and Wellness permission to use your photos taken during your session, 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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