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Company Privacy Policy

We value your privacy. We do not disclose your personal information or share it with other outside entities unless otherwise authorized by you. Your information is used for internal statistics, marketing, or education purposes. We do not send spam emails. We only communicate with out clients and potential clients regarding new services, price changes, special offers, and appointment notifications.
Medical History:

Current Conditions, Previous Discomfort, Stinging or Adverse Reactions: Please check all that apply:
Click to customize checkboxes
Arthrits
Fever
Hypertension
Skin Disease
Tuberculosis
Bells Palsy
Pregnant
Transplant(s)
Acute Inflammation
Melanoma
Cancer/Tumor
Infectious disease
Varicose Veins
Under influence of drugs
High Triglycerides
Kidney Disease
Communicable Disease
Neurological Disorder
Cardiovascular Conditions
Thrombosis or Thrombophlebitis
Diabetes
Organ Failure
Heart Disease
Liver Disease
Unhealed Wounds
Epilepsy
Metal Implants
Pacemaker/Other Electronic Device
High Cholesterol
Dislocations
On Hormonal Medication
Client Consent Form
I have voluntarily elected to receive treatment after the nature and purpose of this treatment have been explained to me. *
No
Yes
I understand that treatments provided can be used to break down fat and cellulite, but are not intended to be a weight loss solution. *
No
Yes
I understand treatments received do not treat medial conditions, nor does it claim or guarantee to treat or relieve any medical condition. *
No
Yes
I understand that there are no guarantees that the treatment will be effective and that to ensure maximum results, multiple treatments will be necessary. *
No
Yes
I understand that the following conditions preclude me from having this treatment at this time, and verify that none of the following conditions apply to me at this time: Cardiac issues, pregnancy, infected, inflamed, or swollen skin, metallic implant, cancer*
No
Yes
I have cited all conditions and circumstances regarding my health history, medications being taken, and any past reactions to products or medications. *
No
Yes
Any recommendation for changes in diet & nutrition including the use of food supplements and weight reduction products are entirely my responsibility and I should consult a physician prior to undergoing any dietary or food supplement changes. I agree that I am voluntarily participating in these activities and assume all risks of injury, illness or death.*
No
Yes
Video and Photo Release

I grant and authorize the Body Sanctuary the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, layers, posters, brochures, advertisements, press kits, websites, social media sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known and later discovered. I will be consulted about the use of the photograph and/or video recording for any purpose other than those listed below: Promotional materials Printed and/or digital advertisements Educational presentations or courses Informational presentations Online education courses Educational videos Social media posts There is no time limit on the validity of this release, nor is there any geographic limitation on where these materials may be distributed. By signing this form, I acknowledge that I have completely read and fully understand the above release and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.
Click to customize question*
No, I do not agree
Yes, I do agree
COVID-19 Liability Waiver

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and the federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Body Sanctuary has put in place preventative measures to reduce the spread of COVID-19; however The Body Sanctuary cannot guarantee that you will not become infected with COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that I may be exposed to or infected by COVID-19 by attending The Body Sanctuary and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at The Body Sanctuary may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death, illness, damage, loss, claim, liability, or expense, of any kind, to myself and to those in my family that are exposed to me, that I may experience or incur in connection with my attendance at The Body Sanctuary.
Click to customize question*
No
Yes, I agree

Click to customize date box label *
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*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

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

First Name*

Middle Name

Last Name*
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.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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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