CLIENT SURVEY AND MEDICAL HISTORY Name: Address: City, State, Zip: Email: Cell Number: Home Number: Occupation: Birthdate: How did you hear about us? Do you have a history of or are you currently experiencing any of the following? Epilepsy Kidney/Urine Infections Diabetes Cancer Hormone Replacement Therapy Contraceptive Autoimmune Disease Currently Pregnant or Breastfeeding Current Infection, Fever, or Disease Cardiovascular Conditions Thyroid Problems Metal Pins/Plates/Implants Skin issues Digestive Problems Circulation Problems Gynecological Conditions Nervous System Conditions Immunodeficiency Disorders HIV Y N Comments: Pill/ IUD/ Other Thrombosis/ Phlebitis/ Hypotension/ Hypertension/ Heart Disease Dermatitis/Light Sensitivity Constipation/ Bloating/ Gallbladder/ Stomach Heart/ Blood Pressure/ Fluid Retention/ Varicose veins Irregular Periods/ PMT/ Menopause Migraines/ Tension/ Stress/ Depression 1
List any medical condition(s) currently being treated by a practitioner: List all medications, vitamins, and supplements that you are currently taking: List any known allergies: List any previous infrared body wrap & body contouring procedures: Area interested in treating: 2
TREATMENT AGREEMENT AND CONSENT FORM I,, duly authorize the technicians of Bliss Beauty Studio to perform treatment (s) for the purpose of spot fat reduction and/or improving the appearance of cellulite. I am aware that clinical results may vary depending on individual factors, including, but not limited to, medical history, client compliance with pre/post treatment instructions, and individual bodily response to treatment. I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained. I understand that ultra-cavitation/radio frequency Body Contouring and Infrared Body Wrapping involves a course of treatments and all sales are final. Services and treatment packages are non-refundable and non-transferable. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place. I am fully aware that should I wish to cancel the course, the outstanding treatment value is non refundable. For your convenience, we accept cash, Visa, Master Card, and American Express. The course cost is $ for treatment sessions. Individuals with any of the following conditions are not candidates for treatment with Body Contouring treatments or Infrared Body Wrapping. Contraindications include: Pregnancy Epilepsy Uncontrolled Thyroid Gland Dysfunction Uncontrolled Hypertension Cardiac Arrhythmias or Heart Disease Pacemakers Recent or current history of cancer, or actively undergoing radiation or chemotherapy Liver/Kidney Disease Photosensitivity to 650 ~ 660nm of light Immuno-suppressed disorders Current Infection (including viral) 3
I understand that with some skin types, there is a risk of temporary redness and/or discoloration of the skin localized in the treatment area that can last up to several hours. There is also a possibility of tattoo lightening if located in the treatment area. I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes, and possible complications. I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so. I understand that it is my personal responsibility to inform the technician of the clinic named above of any changes to my medical history during the course of my body contouring treatment sessions. I confirm that should this occur, I shall advise the technician of any changes. I certify that I have been given the opportunity to ask questions, any questions have been answered to my satisfaction, and that I have fully read and understood the contents of this consent form. Client Signature: Date: Staff Initials: 4
Pre/Post Treatment Instructions: Avoid eating two hours before and after treatment sessions. Avoid heavy meals on the treatment days. Drink plenty of water to facilitate lymphatic drainage. Limit carbonated drinks, coffee, and tea during treatment period Avoid fasting or the body will go into starvation mode and become more resistant to the release of stored fat. If you opt to forego the Skinny Dip Body Wrap in conjunction with your Body Contour: Within the first two hours following a ThermaSculpt Body Contour Treatment, the client MUST perform on their own, 30-45 minutes of a cardiovascular workout in order to create the energy demand that will facilitate metabolism of the fatty acids and glycerol freed from the fat cells. Please consider contraindications or other medical issues that may impact the results of this treatment. Some medical disorders that may reduce first treatment response include thyroid, immune, lymphatic related conditions, pre-menopause, menopause, diabetes, and infection (including viral). Wear clothing that will facilitate the probe s placement in the treatment areas for easy access. I certify that I have been counseled in the pre and post treatment instructions and have been given a copy of them. I have read and understand the instructions and realize that I must follow these instructions diligently in order to obtain optimum results. Client Signature: Staff Initials: 5
LIABILITY WAIVER I,, acknowledge that I will be engaging in unsupervised activities in Bliss Beauty Studio which may lead to personal injury. I agree to assume all responsibility for any personal injury that may occur. I hereby authorize Bliss Beauty Studio staff to act on my behalf, if I am unable to do so, to the best of their ability in an emergency requiring medical attention. I assume personal responsibility for any damages that may result from an injury. I furthermore agree not to hold Bliss Beauty Studio responsible for any injury that might occur during my participation in all activities associated with Skinny Dip Body Wrap performed at the Bliss Beauty Studio facility. Client Signature: Date: Staff Initials: EMERGENCY CONTACT INFORMATION Emergency Contact Name: Emergency Contact Phone Number: Relationship to Client: 6