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Ageless Sculpting & Wellness
Consent Form 2022



Review Ageless Sculpting & Wellness, LLC Privacy Policy

I acknowledge the contagious nature of the COVID-19 virus, and respect that the CDC and many other public health authorities still recommend practicing social distancing.

I further acknowledge that Ageless Sculpting & Wellness has put in place preventative measures to reduce the spread of the COVID-19 virus, to the best of their abilities.

I further acknowledge that no guarantee exists regarding whether or not I may contract COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 virus may result from the actions, omissions, or negligence of myself and others, including, but not limited to, staff and other clients.

I acknowledge that I increase my risk of exposure to COVID-19 by participating in services rendered. I acknowledge that I must comply with all set procedures to reduce the spread while in attendance.


I attest that:

* I, nor members in my household, are not experiencing any symptom of illness such as cough, shortness of breath, difficulty breathing, fever, chills, muscle pain, headache, sore throat, or new loss of taste or smell.

* I, nor members in my household, have not traveled internationally within the last 14 days.

* I, nor members in my household, have not traveled to a highly impacted area within the United States in the last 14 days.

* I, nor members in my household, do not believe we have been exposed to someone with a suspected and/or confirmed case of COVID-19.

* I, nor members of my household, have not been diagnosed with Coronavirus/Covid-19 by state or local public health authorities.

* I am following all CDC recommended guidelines as much as possible, including limiting any purposeful exposure to COVID-19.


I hereby release and agree to hold Ageless Sculpting & Wellness, LLC, harmless from any causes of action, claims, demands, damages, costs, expenses and compensation for damage to myself that may be caused by any act, or failure to act, or that may otherwise arise in any way with any services received. I understand that this release discharges the aforementioned from any liability with respect to bodily injury, illness, death, medical treatment, or property damage that may arise from, or in connection to, any services received. This liability waiver and release extends to all owners, partners, and employees.


Cancellation Policy: Please reschedule or cancel at least 24 Hours before your scheduled appointment, otherwise, you will be charged a cancellation fee of 45% of the amount of the service that was to be provided, regardless of the type of appointment. You may cancel or reschedule your appointment via our website, text or voicemail.

I understand Ageless Sculpting & Wellness, LLC's cancellation policy and agree to pay the cancellation fee. If I cancel/reschedule my appointment with less than 24 hours notice, I understand that my credit card information is safe on file and will NOT be charged unless the cancellation criteria have not been met.

INFORMED CONSENT

I understand that the Ultraslim Protocol includes the use of a specific type and dose of red light emitted through a phototherapy system which is FDA cleared to treat the skin with 126 joules/cm2 emitted 17 cm from the skin for 20 minutes or 50.4 joules/cm2 for each 8 minute body contouring treatment.

Phototherapy requires good general health and that the ability to process waste is not impaired. If you have liver, lymphatic, or kidney problems, or have any serious medical condition, ask your doctor before beginning phototherapy. Do not start phototherapy if you are photo-sensitive or take a photo-sensitive medication. Phototherapy is not for those who are pregnant or trying to become pregnant.

I understand this is an elective, cosmetic procedure and that the prescribed series of treatments is required to achieve desired results. I ASSUME ALL RISKS AND ACKNOWLEDGE THAT NO GUARANTEE HAS BEEN MADE TO ME CONCERNING THE RESULTS OF THIS PROCEDURE. I understand that I must follow the pre- and post-treatment regimen. Failure to follow the outlined Client Protocol may result in failure to achieve the desired results. I am not now, and do not expect to become pregnant during the course of my treatment. The staff has explained the procedure and its risks, benefits and alternatives, including not doing the procedure, and have answered all my questions. 



First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Middle Name

Last Name*

Phone*
Tenth Participant's Date of Birth*
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 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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