Client Intake Form

First Name *

Last Name *

Email *

Phone *

Emergency Contact Name *

Emergency Contact Phone Number *

Age *

Weight *

Height *

Please check any of the following chronic medical conditions, allergies, or health concerns that apply to you: *

Areas of Concern *

Desired Outcomes *

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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, Cancer, Infected, inflamed, or swollen skin, Metallic Implant (pacemaker), Pregnant/Lactating

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I certify I am over the age of 18

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I have voluntarily elected to receive body sculpting after the nature and purpose of this treatment has been explained to me.

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I understand that body sculpting can be used to reduce fat deposits, but is not intended to be a weight loss solution.

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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.

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I recognize there are no guaranteed results.

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I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: Redness, Swelling, Irritation, Skin reaction, and/or Increased heart rate.

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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.

Photo Disclaimer *

I consent to the use of any photographs taken during the body sculpting procedure for documentation, educational, or promotional purposes by the technician or establishment. I understand that my identity may or may not be disclosed in conjunction with these photographs. I waive any right to inspect or approve the finished product where my likeness appears and release the technician and establishment from any associated claims or liabilities.

Consent and Declaration:

I acknowledge that I have read, understood, and accept the terms outlined in this agreement, including the risks associated with the body sculpting procedure. I assume full responsibility for any injuries, losses, side effects, or damages that may occur during the procedure, and I absolve the technician of responsibility for any undisclosed conditions that may be affected by the treatment.

Furthermore, I certify that the information provided in this form is accurate to the best of my knowledge and belief. I agree to promptly inform the technician of any changes to this information and any discomfort experienced during the treatment. I confirm that I do not have any conditions that would render the treatment unsuitable. I hereby waive all liability toward the technician and the salon for any injury or damages resulting from any misrepresentation of my health.

Signature *

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