Body Contouring Intake Form ContactName(Required) First Last Email(Required) Phone(Required)Phone Type(Required) Home Mobile Work Other It's OK to text me! Yes No Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code ContradictionsSelect all that applies to you(Required) Recent Surgical Procedure Diabetes High Cholesterol Pregnant Allergies Cancer Cardiac Issues Epilepsy Fainting Spells Thyroid Issues Blood Pressure Issues History of Liver Problems History of Colon problems including protruding/distended belly Agreement(Required) I accept the following statements.• No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments are required for desired results. Most guests require a number of treatments over several months with gradual results occurring after each session. • I understand that body contouring can have certain side effects such as skin redness, swelling, tenderness, cardiac issues etc. • I understand that compliance to my post-care instructions will greatly affect my result. I acknowledge my obligation to follow the written and spoken instructions covering my pre- and post-treatment body skincare regimen. • I consent to photographs being taken to evaluate treatment effectiveness. No photographs revealing my identity will be used without my written consent.Consent(Required) I agree to the notice.My signature below constitutes acknowledgement that I have read and understand the foregoing consent form and agree to the treatment. I hold harmless LaVida Massage + Skincare, the Esthetician, and affiliates of all circumstances that may occur during my treatment. I agree that I am willing to follow recommendations by my Esthetician for home care. I will be responsible for following home regimens that can minimize or eliminate possible negative reactions, including recognizing the importance of adhering to sunscreen and avoiding the sun/tanning booths and extreme weather conditions. If I may have additional questions or concerns regarding my treatment or suggested home product/post-treatment care, I will consult my Esthetician immediately. I HEREBY AFFIRM: I AM 18 YEARS OF AGE OR OLDER. I HAVE CAREFULLY READ THIS DOCUMENT, AND I UNDERSTAND ITS CONTENTS. I AM AWARE THIS DOCUMENT IS A RELEASE OF ALL LIABILITY AND A CONTRACT ENFORCEABLE AGAINST ME (AND MY HEIRS, NEXT OF KIN, DISTRIBUTEES, GUARDIANS, LEGAL REPRESENTATIVES, EXECUTORS, ADMINISTRATORS, SUCCESSORS AND ASSIGNS) IN A COURT OF LAW. I HAVE SIGNED THIS DOCUMENT OF MY OWN FREE WILL. By signing below, I agree I have read and agree to the legal agreements above.Signature(Required)EmailThis field is for validation purposes and should be left unchanged.
