Intake Form Book Now Name * First Name Last Name Email * Phone (###) ### #### What services are you interested in? Fat Reduction 360 Fat Reduction Booty x Waist Non-Surgical BBL Skin Tightening Cellulite Reduction Facial Sculpting Lymphatic Detox How did you hear about us? Instagram A friend Other Read through the following contradictions to ensure body sculpting is the right fit for you: Pregnant Patients with any implants to do with heart valves Patients using skin-thinning or sun-sensitive medications Patients with liver disease or malfunctioning liver Patients with kidney disease or malfunctioning kidneys Patients with cancer or who are currently undergoing cancer treatments Patients with high fever None of the above apply to me Read through the following risks to ensure body sculpting is the right fit for you : Blisters (Rare) Temporary Redness Swelling Bruising Tenderness I confirm I'm undergoing these treatments at my own risk and will not hold the service provider responsible Do you have any metal medical devices implanted? Yes No Do you have high blood pressure? Yes No Do you have an allergy to latex? Yes No Do you consent to us posting your before and after photos? (No face included, tattoos + markings blurred) Yes No Do you have any thyroid gland dysfunction? Yes No Do you have epilepsy Yes No Have you undergone an organ transplant? Yes No Do you have any current infections? Yes No Risks + Contradictions Do you have any chronic medical conditions or have undergone any serious surgeries we should be aware of? I hereby declare that I am of legal age and I understand that treatments for body sculpting do not guarantee absolute results. In order to achieve my desired results, I may be required to undergo several treatments with an appropriate diet and exercise Yes No I hereby release and forever discharge the Clinic, its affiliates, partners, agents, and employees from any and all causes of action. I will hold harmless, the Clinic for any liabilities, damages, injuries whether seen or unforeseen. Yes No I understand that any procedure under the Clinic does not constitute medical treatment or cure to any illness. Yes No By signing this form, I declare that all information and declarations I have made above are true and correct to the best of my knowledge. Yes No I have likewise read all the information above and give my consent with my full knowledge, understanding, and assumption to the risks involved in the treatment, without any coercion, inducement, or undue influence. Yes No Dream Body Loading... Ready To Experience Our Personalized Services?
