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WAIVER & RELEASE

 

Acknowledgment of Risks, Injury & Obligations

I acknowledge that the activity I am to undertake is a dangerous activity and that by participating in it I am exposed to certain risks. I acknowledge and understand that whilst participating in such activity:

I acknowledge that I am taking my own risk and agree to hold Bodyzone Fitness and Wellness Studio LLC harmless for any adverse reaction to treatment.


First Participant's Name

First Name*

Last Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First 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*

Emergency Contact's Relation to Participant
Medical History

Weight

Height
Please check all that apply: *
AIDS
Alcoholism
Auto immune Deficiencies
Dermal Disorders
Diabetes
Endometriosis
Fibrosis
Heart Disease
High Cholesterol
High/Low Blood Pressure
Infectious Disease
Internal Bleeding
Keloids
Kidney Disease
Liver Disease
Metal Implants
Neurological Disorder
Pacemakers/ Other Electronic Device
Pregnant/Nursing
Psoriasis
Ringworm
Thrombosis or Thrombophlebitis
Thyroid Issues
Transplant/Transplants
Turberculosis
Unhealed Wounds
Do you have any other medical conditions that we should know about? *
Yes
No
Are you currently taking any medications? *
Yes
No
Do you have any allergies? *
Yes
No
Have you had any surgery in the last 5 years? *
Yes
No
Do you have any medical devices implanted including but not limited to, hearing aids, a pacemaker or hormonal pellets? *
Yes
No
Do you use recreational drugs? *
Yes
No

When was the first day of your menstrual cycle?

If you answered yes to any of these questions , please explain? *
Service Information
Do you want to lose body fat? *
Yes
No
Do you want to tighten skin on your body? *
Yes
No
Do you want to reduce cellulite? *
Yes
No

Please list your regular exercise habits: *

Please describe your current dietary habits: *

How many ounces of water do you drink daily? *
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. I have read and fully understand this agreement and all information detailed below. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects or damages that may occur to me while i am undergoing this procedure. I do not hold the technician responsible for any of my conditions that were present, but not disclosed at the time of this procedure, which may be affected by the treatment performed today.


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