I understand Body Contouring does not treat medical conditions nor does it claim or guarantee to treat or relieve any medical condition.
I understand that any procedure involves risk. Risks may include redness, swelling, irritation, skin reaction, or increased heart rate.
I have been honest and forthright about my medical history, and i am healthy to use the devise. I am not pregnant, have any metallic implants (including a pacemaker), not any other disease or condition that may be negatively impacted by the body contouring device.
Acknowledgement: I understand each person has a different response to the Body Contouring treatment. The Risks, benefits, and possible results have been explained to me. I have been provided the opportunity to ask questions and received satisfactory responses.
I voluntarily provide my consent to partake in the Body Contouring treatment. Should any pain or discomfort occur, I will immediately notify staff. I will not hole the service provider liable for any irritation or effects of having thermal heat applied.
Body Sculpting increases the flow of both the lymphatic and circulatory systems, and it also helps with cleaning of the tissues. The main use of body sculpting os inch loss, diminishing of cellulite, and tightening of the skin.
Lose 1-3 inches per treatment with state-of-the-art equipment. Benefits are often immediate, but may be delayed in some people.
For Best Results:
A Series of 9-12 body sculpting treatments are recommended per each area, but some individuals may require more treatments to achieve maximum results. There should be at least 1-2 days between each treatment. This is not a weight-loss treatment, but an inch loss. The inches will only return of the client goes back to their old habits. Eating the right types of food, proper exercise, and drinking 8 glasses of water per day are always recommended. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar and alcohol for 24 hours after each treatment.
Body sculpting treatments are not recommended of you are pregnant, breastfeeding, have a lymphatic disorder, acute illness, metal implants, pacemakers, or are currently being treated for active cancer.
I understand that I am using the Relaxed Fitness Vibration 360 machine provided at my own risk. Should I sustain an injury while using the equipment, I agree to not hold the service provider responsible.
I understand and acknowledge that payments for the avobe services are non-refundable. by my signature below, i certify that i have read and understand the contents of this consent form for Body Contouring. I further agree to provide 24 hour notice of a cancellation or change in appointment time, or i will forfeit a treatment off my package, since treatments are by appointment only. There are no refunds if I am responding to treatment and decide to stop treatment. Should I decide to add an ultrasound treatment and/or a Radio Frequency treatment, that treatment will be considered an additional and separate treatment. This extra treatment can be paid for separately or deducted from the number of treatments in my Cold Laser Package. Should the service provider wish to use any photos of my progress other than for my personal file, I will sign a separate Photo Release Form.
If there is a need to cancel for any reason, we ask for a 24 hour notice. Please understand that when you do not cancel or show up for an appointment, it is a cost to us. If you cannot provide us with a 24 hour notice, we may impose the following fees:
“No Show” for session: Loss of that treatment in your treatment package
Same day cancellation: 100% charge before your next scheduled treatment
We are taking extra precautions with the intake of each client, as well as sanitation and disinfecting practices. It is required that you fill our this form and submit it PRIOR to your appointment. Please read our policies, complete the following, and sign below.
I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained tome, along with the risks and hazards involved, by my esthetician.
Dermaplaning involves the use of a sterilized surgical blade to remove fine vellus hair from the face, and provide light exfoliation.
If an unforeseen condition arises in the course of the procedure, I authorize my therapist to use his/her professional judgment to decide what he/she feels is necessary under the given circumstances.
Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications. I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is the possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.
I have read and understand the post-treatment home care instructions. I understand how important it is to follow all instructions given to me for post-treatment care. In the event that I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult the esthetician immediately.
I have also, 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.
The result of the procedure can be affected by the following: medication, skin characteristics (dry, oily, sun-damaged thick or thin skin type), personal pH balance of your skin, alcohol intake and smoking, post procedure after care.
Upon completion of the procedure there might be swelling and redness of the skin. In some cases, bruising may occur. You may resume normal activities following the procedure, however, using cosmetics, excessive perspiration and exposure to the sun should be limited until the skin has fully healed.
To my knowledge, I do not have any physical, mental or medical impairment or disability that might affect my well being as a direct or indirect result of my decision to have the procedure done at this time.
I acknowledge that side effects can occur and I fully accept the risk. I understand that my Esthetician, will take every precaution to minimize or eliminate negative reactions as much as possible.
I have read the information and recorded my medical history accurately with all pertinent information. For future services, I agree to inform my spa technician of any changes in my medical status and/or the above information. I understand spa services are not to be considered medical treatment, and as such, the spa technician cannot prescribe treatment of pharmaceuticals
The nature and purpose of Dermaplaning has been explained to me and any questions I have regarding the treatment have been answered to my satisfaction prior to procedure.
I confirm that the information given above is correct, and that to my knowledge, I have not withheld any information that may be deemed relevant to the treatment I am receiving. I acknowledge that there are potential risks and complications to receiving any procedure, and I take responsibility for any side effects should they occur. I consent to the dermaplaning treatment with the understanding that it is an elective procedure, no medical claims are expressed.
I certify that I have read and fully understand the above paragraphs, that I have had sufficient opportunity for discussion and to ask questions, and that I hereby consent to the procedure described above.
Ultrasonic Cavitation are technologies for breakdown of the fat deposits. These procedures do not involve invasive surgery – there is no need for anesthesia, hospital stay and no down time. They provide a non-invasive method to break down stubborn fat deposits that never seem to disappear no matter what your diet is or how hard you exercise. The most problematic body areas are abdomen, flanks (love handles), inner thighs, buttocks, inner knees, under chin and upper arm.
Appointments are usually scheduled every 2-3 times a week. In order to ensure maximum results, it is necessary to follow the recommended treatment schedule. The total number of treatments will vary between individuals. On occasion, there are patients that do not respond to treatments.
By completing this client profile, you will assist us in evaluating your condition. The information you provide will be used to determine what factors may be affecting you so that we may recommend the proper care.
I have read, agree to, and understand the following:
• The goal of any treatment, as in any cosmetic procedure, is improvement, not perfection, and results may not be perfect due to any genetic, hormonal, nutritional, or topical applications interference or an impact of unpredictable reactions.• Individuals with a past history of herpes simplex virus infections and individuals with no known history of herpes simplex virus infections. Bacterial, fungal and viral infections can occur. Herpes simplex (viral infections) around the mouth can occur following a treatment. Should any type of skin infection occur, check with your physician for proper treatment.• Allergic Reactions: In rare cases, allergies to tape, preservatives used in cosmetics, topical preparations, etc. have been reported. Systemic reactions (which are more serious) may result from prescription medicines.• Compliance with the aftercare guidelines is crucial.• Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled.
I have read and understand all of the above. I have asked any and all questions that I have regarding the procedure of laser lipo/ultrasonic cavitation, pre-treatment and post-treatment. I was given written instructions for post-treatment care at home. I understand completely and will take full responsibility for post-treatment care. All of the treatment fees have been discussed with me and I understand them completely.
My questions regarding the procedure have been answered satisfactorily. I understand the procedure and accept the risks. I hereby release all related staff from all liabilities associated with the above-indicated procedure. By signing this form, I am giving the service provider a permission to treat me, and I understand all symptoms and side effects that may occur during or after treatments, thereby releasing the service provider of all liability regarding these issues.
I understand that only the physician or technician can decide if treatment is NOT appropriate for the following reasons:• Presence of metallic prosthesis
• Acute inflammatory processes• Tumors or cancer
• Cutaneous lesions• Proximity of the organs and the bone marrow
• Pace maker, high blood pressure • Pregnancy / breastfeeding
• Epilepsy• Metal plates in your body
• Gall stones• Active infections, hives, herpetic lesions, or cold sores
• Medications• Extreme sensitivity or allergic reactions in the treated area
• Kidney damage, liver damage or diseases• Hemorrhagic disease, clotting or bleeding
• Medical plastic or parts with meal inside• Abnormal immune system
• Numb or insensitive to heat
If I mislead the physician, technician or student for any of the reasons mentioned above, by signing below I fully understand and take responsibility for the post-treatment consequences. Occasionally, unforeseen mechanical problems may occur and your appointment will need to be rescheduled. We will make every effort to notify you prior to your arrival to the office. Please be understanding if we cause you any inconvenience.
I certify that the above statements are true and correct, and that I have been advised and fully informed by Laser and Lipstick, concerning the nature of the process proposed, to be performed by them, and hereby authorise and direct them to perform such process and perform such services as may be deemed necessary or advisable.
My signature below constitutes my acknowledgement that:1. I have read, understand and fully agree to the foregoing2. Understand the caution and contraindications for each process and service proposed3. Give consent to the proposed process that has been satisfactorily explained to me and my questions have been addressed4. I hereby give my consent and authorization voluntarily and release the service provider and its therapists of any claims that I have or may have in the future in connection with the described application or service.
Although every precaution will be made to ensure your safety and well-being before, during and after your tinting application, please be aware of the possible risks below. Please Select “I Understand”:
I have read the above information. If I have any concerns, I will address these with my skin care therapist. I give permission to my therapist to perform the tinting procedure we have discussed, and will hold him/her and his/her staff harmless from any liability that may result from this treatment.
I have accurately answered the questions above, including all known allergies, prescription drugs, or products I am currently ingesting or using topically. I understand my esthetician will take every precaution to minimize or eliminate negative reactions as much as possible. In the event I may have additional questions or concerns regarding my treatment, I will consult the esthetician immediately.
I agree that this constitutes full disclosure, and that it supersedes any previous verbal or written disclosures. I certify that I have read, and fully understand, the above paragraphs and that I have had sufficient opportunity for discussion to have any questions answered.
I understand the procedure and accept the risks. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
The following information will be used to help plan a safe and an effective massage session. Please answer the questions to the best of your knowledge.
I hereby grant permission to the rights of my image, likeness and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I also understand that this material may be used in diverse educational settings within an unrestricted geographic area. Photographic, audio or video recordings may be used for the following purposes:• educational presentations or courses• informational presentations• on-line educational courses• educational videos• promotional materialsBy signing this release I understand this permission signifies that photographic or video recordings of me may be electronically displayed via the Internet or in the public educational setting.I will be consulted about the use of the photographs or video recording for any purpose other than those listed above.There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.This release applies to photographic, audio or video recordings collected as part of the sessions listed on this document only.
General information about your pregnancy/health history is helpful in planning a massage session that is safe and effective.
Please check any health condition listed below (or add) that applies to you in your past or present:
The following information will be used to help plan a safe and an effective massage session.Please answer the questions to the best of your knowledge.
Please indicate any of the following that apply to you:
Please rate the following on a scale of:
This information has been given to me so that I can make an informed decision about having my teeth whitened. I may take as much time as I wish to make my decision about signing this informed consent form. I have the right to ask questions about any procedure before agreeing to undergo the procedure. I would like to have my teeth lightened via the “in-office” technique.
DESCRIPTION OF THE PROCEDURE
In-Office Whitening is a procedure designed to lighten the color of my teeth using a hydrogen peroxide gel. The In-Office Whitening treatment involves using the gel to produce maximum whitening results in the shortest possible time.
During the procedure the whitening gel will be applied to my teeth for two or three 20-minute sessions, with an optional fourth 20-minute session. During the entire treatment, a plastic retractor will be placed in my mouth to help keep it open and the soft tissues of my mouth (i.e. my lips, gums, cheeks and tongue) will be covered to ensure they are not exposed to the gel.
Lip balm may also be applied as needed and I will be provided protective eyewear for my eyes. After the treatment is completed, the retractor and all gel and tissue coverings will be removed from my mouth. Before and after the treatment, the shade of my upper-front teeth will be assessed and recorded.
RISKS OF TREATMENT
I understand that In-Office whitening treatment results may vary or regress due to a variety of circumstances. I understand that almost all natural teeth can be lightened from In-Office Whitening treatment. I understand that In-Office Whitening treatments are not intended to lighten artificial teeth, caps, crowns, veneers or porcelain, composite or other restorative materials and that people with stained teeth.
I understand that teeth with multiple colorations, bands, splotches or spots due to tetracycline use or fluorosis do not whiten as well, and may need multiple treatments or may not whiten at all. I understand that teeth with many fillings, cavities, chips or cracks may not lighten and are usually best treated with other non-bleaching alternatives.I understand that the results of my In-Office Whitening cannot be guaranteed.
I understand that although my dentist/hygienist has been trained in the proper use of the In-Office Whitening system, the treatment is not without risk. I understand that some of the potential complications of this treatment include, but are not limited to:
Tooth Sensitivity is is normal and is usually mild, but it can be worse in susceptible individuals. Usually, tooth sensitivity or pain following a whitening treatment subsides after a few days, but it may persist for longer periods of time in susceptible individuals. People with existing sensitivity, recession, exposed dentin, exposed root surfaces and large wear facets (severely worn teeth), damaged or missing enamel, cracked teeth, cavities, leaking fillings, or other dental conditions that cause sensitivity or allow penetration of the gel into the tooth may find that those conditions increase or prolong tooth sensitivity or pain after whitening treatment.
After the whitening treatment, it is natural for teeth that underwent the whitening treatment to regress somewhat in their shading after treatment. This is natural and should be very gradual but it can be accelerated by exposing the teeth to various staining agents. Treatment usually involves wearing a take home tray or repeating the whitening treatment.
I understand that the results of the whitening treatment is not intended to be permanent and secondary, repeat or take-home treatments may be needed further to maintain the tooth shade I desire for my teeth. I understand that after treatment, I will be required to refrain from consuming any substances that could discolor my teeth for the first 48 hours after treatment. These substances include: coffee, teas, and colas, ALL tobacco products, mustard or ketchup, red wine, soy sauce, berries, berry pie, and red sauces.
Since it is impossible to state every complication that may occur as a result of whitening treatments, the list of complications in this form is incomplete. The basic procedures of whitening treatments and the advantages and disadvantages; risks and known possible complications of alternative treatments have been explained to me by my dentist/hygienist and my dentist/hygienist has answered all my questions to my satisfaction.
In signing this informed consent I am stating I have had this informed consent (or it has been read to me) and I fully understand it and the possible risks, complications and benefits that can result from the whitening treatment and that I agree to undergo the treatment as described by my dentist and/or their staff.
1. General InformationTeeth whitening is designed to lighten the color of your teeth. Significant lightening can be achieved in the vast majority of cases, but the results cannot be guaranteed. When done properly, the whitening will not harm your teeth or gums. However, like any other treatment, it has some inherent risks and limitations.
These are seldom serious enough to discourage you from having your teeth whitened, but should be considered when deciding to have the treatment.
2. Candidates for Teeth WhiteningJust about anyone is a candidate for teeth whitening. However, the following cases should be considered:• People with dark yellow or yellow‐brown teeth tend to whiten better than people with gray or bluish‐gray teeth.• Multi‐colored teeth, especially if due to tetracycline, do not whiten very well.• People with significant periodontal disease are not good candidates• If you are pregnant, obtain permission from your doctor before trying the whitening procedure.• People with minimal discoloration, (teeth that are already very white) may not see a substantial degree of whitening.• Teeth with many fillings, cavities, chips, etc., are usually best treated by bonding, porcelain veneers or porcelain crowns. Any current restoration you have, such as, fillings, porcelain crowns, onlays and inlays cannot be whitened.
3. Types of Teeth Whitening• IN-OFFICE WHITENING ‐ This process can be done in one visit or may require multiple visits depending on how your teeth respond to the whitening gel. Each appointment takes approximately one to two hours (1/2‐1 hour preparation and 1 hour treatment)The advantages of In-office whitening include our doing all the work for you and in less total time than you would spend at home whitening your teeth. The disadvantages include the normal inconveniences of any dental treatment, such as, having to keep your mouth open for the duration of the appointment and the possibility of increased costs as compared to home whitening.• TAKE-HOME WHITENING ‐ This process, which can be done anywhere and anytime, involves wearing a custom‐made whitening tray (looks like a thin, transparent mouthguard) filled with a mild whitening agent for optimal results. You should wear the gel‐filled tray from 45 minutes per day to overnight depending on the strength of the whitening agent. You should continue treatment for about one to two weeks, depending on the degree of whitening desired. The advantages of home whitening include performing the treatment when it isconvenient for you with lower costs. The disadvantage to home whitening is that the success of the treatment is dependent on your commitment to wearing the whitening tray consistently for the prescribed period.
4. YOUR RESPONSIBILITIES• WEARING YOUR WHITENING TRAY ‐ If you choose home whitening, it will only be effective if you conscientiously wear the tray for the prescribed time for the one to three weeks.• COMPLICATIONS ‐ If you experience any severe discomfort or other problems, discontinue the whitening and contact us immediately. Most sensitivity is usually transient and disappears after one to several days.
5. Potential Problems• TOOTH SENSITIVITY ‐ During the first 24 hours following whitening, some patients experience transient sensitivity. This sensitive is usually mild if your teeth are not normally sensitive. With power whitening, this sensitivity will usually subside in 1‐2 days. With home whitening, it may be necessary for you to reduce the number of minutes or hours you are wearing the whitening trays or stop using if for several days to resolve the sensitivity.
However, if your teeth are normally sensitive, whitening may make your teeth more sensitive for an extended period of time. Under these circumstances, you may choose to delay the whitening process until we are able to complete desensitization procedures.If your teeth are sensitive after whitening, a mild analgesic such as Tylenol or Advil will usually be effective in making you more comfortable until your tooth sensitivity returns to normal.• GUM IRRITATION ‐ This is the result of a small amount of solution leaking under the gum protection. A burning sensation on your gums may also occur. This should resolve by itself between a few hours to a few days. You may also experience burning and /or swelling of the lips. With home whitening, irritation can result from over filling your trays causing leakage onto the gum tissue. Irritation can also occur if you are using the tray for too many hours when you first start whitening. It may be necessary for you to reduce the amount of gel placed and reduce the amount of time you are wearing the trays or stop wearing for a few days.• EFFECT ON FILLINGS ‐ Tooth colored fillings will not whiten. If the filling matches your current color, whitening will result in mis‐matched shades with your natural teeth. You may need to have your fillings replaced to match you newly whitening teeth.
6. Completion of Treatment• LEVEL OF LIGHTENING – There is no totally reliable way to predict how light your teeth will whiten. With power whitening, one session usually significantly whitens your teeth. Some patients require an additional session. With home whitening, this may take two to four weeks or longer of repeated applications.• RELAPSE ‐ Following completion of whitening, pigments found in food and drinks will re‐stain your teeth, commonly called whitening relapse. You may use daily whitening toothpaste, available in drug stores.
Please read carefully and understand the contents of this form. Ask us if you do not understand.
When a client seeks Body Contouring services and when the service provider accepts a client, it is essential that both are seeking and working for the same goals. We expect our clients to take full responsibility for their decisions to participate in any of the services. programs offered by this office, We do not identify, diagnose, or treat ANY condition or disease. We have only one goal: TO OPTIMIZE YOUR BODY’S ABILITY TO FUNCTION NORMALLY AND OPTIMISE YOUR FAT-BURNING POTENTIAL. By reducing bio-stress levels, we allow the body’s inborn self-correcting mechanism to work at maximum efficiency to restore, maintain, and promote wellness.
We do not identify or diagnose any condition(s) or disease(s). We offer no treatment for any condition(s) or disease(s). We promise no cure from any disease(s) or condition(s). Instead, we facilitate your body’s own self correcting mechanism.
It is essential that you speak to your doctor prior to making any decisions about altering any medical regimen you are currently following, changing your diet, taking supplements, or going on an exercise and/or/weight loss program. Getting your doctor’s approval prior to starting any service/program at our office is critical and solely your responsibility. Should any health condition arise while you are a client, we recommend that you immediately see the appropriate health care provider.
Any options that are rendered by the staff and/or head personnel should never be construed as medical advice but merely as opinions. If you would like medical advice, please see one of out medical doctors. We will not deal with any medical condition(s).
With your signature below, you understand and voluntarily accept these risks and agree that neither the service provider, it’s staff, or any of it’s partners will be liable for any injury to you, including, but not limited to, personal bodily injury, death, mental injury, economic loss or any damage to you, your spouse, or relatives resulting from any act of the service provider. with all respect to your current or past condition(s). If there is any dispute between you and the service provider, and/or any of it’s staff, both parties agree to submit it to binding arbitration. We both agree to have a neutral arbitrator preside over any such dispute, not a judge or jury.
There are times when it is not beneficial for a woman to have a Vajacial/V-Steam. First, Let’s check and make sure that you don’t have any contraindications.
The above “Yes” replies indicate that vaginal steaming is contraindicated. It is not safe and could result in negative side effects such as the onset of bleeding or a miscarriage. Steaming should not be performed at this time.
If you are using the above birth control methods, vaginal steaming could cause a birth control failure. It is not recommended unless you are okay with a backup for of birth control or you are not concerned about a possible pregnancy. If you have a burning itch, the warmth from the steam could be uncomfortable since there is already so much heat in that area. In this case, it is best to seek treatment from an acupuncturist to get the burning sensation to go away prior to doing a vaginal steam session.
Some women are very responsive to steam and it can cause a physiological response. If you are in this category, then it is okay to steam, however your practitioner will adjust your steam session and herbs so that it perfectly suits you.
The above “Yes” replies indicate sensitivity in which case a mild setup which should be performed 10-15 minutes. Under no circumstances should clients would have sensitivity use an advanced setup which is 25-30 minute steam sessions.
With my signature below, I give consent to receive treatments from my Service Provider and have read and completed this questionnaire truthfully. I understand that if I experience any pain or discomfort during any session, I will immediately inform the practitioner so that the temperature may be adjusted to my level of comfort. I further understand that vaginal/yoni steam baths should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment of which I am aware. I understand that the practitioner facilitating the vaginal/yoni steam bath is not qualified to diagnose, prescribe, and/or treat any physical or mental illness , and that nothing said in the course of any session given should be construed as such. Because vaginal/yoni steam baths should not be performed under certain medical conditions, I arrifm that i have stated all of my known medical conditions and answered all questions accurately, completely, and honestly. I agree to keep the practitioner updated as to any changed in my medial profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. I am aware and I understand there is a possibility that my IUD can come out due to a Vaginal steam bath. This has been explained to me and I am going ahead with the Vaginal Steam Bath at my own risk. I understand that I am having this vaginal /yoni steam bath at my own risk and hereby release my service provider and its contractors and/or employees from any liability.
Please drink plenty of water before you go in and plenty more when you come out.
If you start to feel nausea, headache, dizziness, fainting, burning, or rapid heartbeat, leave the heat immediately and notify your service provider.
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