Body Sculpting Intake Form ContactName(Required) First Last Email(Required) Phone(Required)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 Date of Birth Age Reason for VisitClient Goal AssessmentWhat is most important to you when choosing services to help you meet your body goals?Areas of Desired Improvement Face/Neck Breast Lift Abdomen Side Waist/Flanks Upper Back/Bra Area Inner Thighs Outer Thighs Back Thighs Front Thighs Buttocks Calves/Lower Legs Upper Arms Present Medical HistoryDo any of the following medical conditions apply to you? (Check all that apply) Pregnancy Epilepsy Cardiac or vascular disease/condition Acute inflammation Unhealed wounds History of internal bleeding Pacemaker or other electronic devices Plastic, bone cement or metal Implants Recent abdominal surgery Abnormal high or low blood pressure Do you get out of breath easily? Do you sometimes get out of breath when sitting still or sleeping? Has a doctor ever told you your cholesterol level was high? Communicable diseases Melanoma Thrombosis or thrombophlebitis Transplants Taking any anti-coagulants Keloids Heart trouble Current Infection Any infectious diseases or tuberculosis Diabetes Kidney or liver disease Thyroid Disorders Please list any medications you are currently takingAre you allergic to any foods or medications? Explain any other current medical conditionsFor females: are you pregnant or nursing? Are you presently under a physician’s care? If so, what for?LaVida Massage of Grand Blanc Treatment Agreement(Required) I accept the following statements.Fees: All costs are to be paid in full prior to initial treatment and are non-refundable. Costs do not include future visits, unless otherwise expressed. Must pay for any special offers on second visit to receive package discount. Discounted packages are non-refundable. Treatment Disclosure: The treatment is a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit, which depend on the amount of work needed. Actual results vary from person to person and LaVida Massage of Grand Blanc does not guarantee any specific result. Aftercare: Clients are required to drink at least 1.5 liters of water prior to and after treatment sessions on a daily basis when undergoing this procedure. Also, be prepared to complete a 30–45-minute cardio workout. Aftercare instructions have to be followed exactly whether given in writing or verbally. Failure to follow aftercare instructions may compromise the final results of the treatment. Before, During and After Picture: Before, during or after pictures may be taken to document your treatment. These pictures become LaVida Massage of Grand Blanc sole property and are only used for its legitimate record keeping. LaVida Massage of Grand Blanc will ask for your signed consent to use before and after treatment pictures for advertising and marketing purposes. Release: I recognize that there are certain inherent risks associated with the above-described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release and fully discharge LaVida Massage of Grand Blanc (including its officers, members, owners, employees and agents) from any and all damages, costs, expenses, liabilities, cause of action, claims and demands of whatever character in law or equity, whether known or unknown, direct or indirect, asserted or unasserted and whether or not in account of myself or LaVida Massage of Grand Blanc or other third parties whose claims may arise out of, or relate to, the treatment I have requested LaVida Massage of Grand Blanc to perform. It is the intention of the parties, that this agreement binds all parties whose claims may arise out of, or relate to, the treatment or services provided by LaVida Massage of Grand Blanc, including any spouse or heirs of the /client and any children, whether born or unborn. Any legal or equitable claim that may arise from participation shall be resolved under state of California law. Results: I agree that results are subjective and that my lifestyle can mitigate these results; therefore, the cost of the procedures are non-refundable. By signing this agreement, I confirm that I am over the age of 18. I understand that the procedure is permanent, that such procedure has possible adverse consequences and that the procedure is for cosmetic purposes only. I certify that I have read the above paragraphs, fully understand the procedure’s risks and hereby consent to the indicated procedures. This means that I accept full responsibility for these and/or any other complications which may arise or result during or following the procedure, which is to be performed at my request.Signature(Required)PhoneThis field is for validation purposes and should be left unchanged.
