Client Consent | SeasonBlush

CLIENT PROFILE AND MEDICAL HISTORY

Name

DOB

Age

Height

Address

Phone

Emergency Contact (Name and Phone)

Describe any aesthetic services you've received in the last 6 months

Have you consumed at least 3 glasses of water today prior to treatment?

Yes

No, but I will have some now

How did you hear about SeasonBlush?

Describe all surgeries and the year you received them:

List all medications/herbs/supplements currently or recently taken:

List all allergies and your reactions:

List any medical or non-medical condition your technician should be aware of:

Specific Appearance problems and treatment goals:

Skin Description

Skin Conditinon

Dry

Normal

Oily

Acne

Ethnicity

Is your skin fragile or sensitive, if yes describe?

Do you have problems healing from injury to skin, if yes describe?

Have you ever had a cold sore?

Are you primarily inside or outside?

Do you currently use sun block regularly?

By signing below, I verify that I am in good physical condition and the information documented is accurate and complete. I have no physical restriction, condition, or disability which may prevent me from receiving the prescribed skin care and/or body treatment therapies. I hereby give my consent to have the recommended procedures performed on me.

Name of client

Your Signature

Select a date

I understand that certain procedure(s) elected are relatively new and little is known about their long-term safety and effectiveness. I understand that each person has a different response to Body Contouring.

I understand that the procedure(s) do not correct health problems, including but NOT limited to diabetes, heart attack, stroke, high cholesterol, blood clots, lung problems, stomach, intestinal problems, bladder disease, an abnormality of the skin. PUT YOUR BUSINESS NAME HERE is NOT a medical facility and does NOT make medical decisions. You must consult with your Primary Care Physician for medical advice.

I understand that I may need post procedure care. I will dutifully be responsible and compliant with the recommendations from my PUT YOUR BUSINESS NAME HERE Clinician, which may include, but are not limited to skin care products, garments, etc.

I understand that procedures involve risk. Risk may include, but not limited to redness, swelling, irritation, burns, skin reactions, etc. I must immediately report any unusual symptoms known to me to my PUT YOUR BUSINESS NAME HERE Clinician that includes, but NOT limited to being aware of any slight nature or prominence of persistent chills, fever, redness, increased warmth, excessive bruising or swelling, etc. at the sights treated and systematically.

I give PUT YOUR BUSINESS NAME HERE permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential unless I have written permission to disclose this information. I give PUT YOUR BUSINESS NAME HERE professional permission to photograph/video my procedure(s).

I have decided that the benefits of body contouring outweigh the potential for complications and all claims have not been evaluated by any regulatory board. I understand the nature of the procedure(s) and ANY and all possible risks mentioned and not limited to. I attest that I am of clear mind, competent, and not under any distress.

ALTERNATIVE TREATMENTS

It has been explained that other temporary and more permanent treatments are available to sculpt, contour, tone, exfoliate, clean and detoxify the body. Alternative forms of management include receiving NO treatment at all. If treatment is chosen alternative body sculpting therapies and other services offered include the following: Lipo Laser, Ultrasound Cavitation, Vacuum Therapy, Electrotherapy, Vibration, Cold/Hot Wraps, Infrared Rays, Reduction Massage, Lymphatic Drainage, HIFU Vaginal Tightening, Teeth Whitening, Topical Skin Therapies i.e. gels, creams, oils, facials etc. Surgical options include Liposuction, Tummy Tucks, Fat Transfer, Muscle Repair etc. I understand that risk and potential complications are associated with these and alternative forms of non-surgical and surgical treatments.

If there is a need to cancel for any reason, we ask for a 24-hour notice. “NO SHOW” for appointments made outside of normal business hours WILL result in a $50 service charge deductible from prepaid service package. Remaining balance will be applied towards next service appointment with regards to TIME LIMITS FOR SERVICE AGREEMENT

TIME LIMITS FOR SERVICE

Specials, Flash Sales & Promotional Priced Services MUST BE completed within 30 days of purchase date.

Regular Price Services MUST BE completed within 60 days of purchase date.

RELEASE OF LIABILITY

I herein certify that I am not pregnant or nursing.

I understand that NO GUARANTEES OR WARRANTIES have been made to me regarding the outcome or any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service and not desired results from treatments. I have been given the opportunity to ask questions and have received satisfactory answers to those questions by the treating staff representative

I consent to the taking of photographs/video for documentation during my treatment(s) unless otherwise stated with written notice to PUT YOUR BUSINESS NAME HERE. These photos may be used for marketing and/or publication for the further benefit of educating the public. All attempts will be made to protect my identity.

Finally, I certify that I have read and fully understand the contents of this form and that the disclosures referred to the above were made prior to my signing the form below.

NO REFUND OR RETURN POLICY. ALL SALES ARE FINAL.

I ACKNOWLEDGE THAT I HAVE HAD A FAIR OPPORTUNITY TO ASK QUESTIONS ABOUT PUT YOUR BUSINESS NAME HERE'S PROCEDURES FOR BODY CONTOURING AND THE ALTERNATIVE TREATMENTS AVAILABLE. I ALSO ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I UNDERSTAND AND ACCEPT THE POTENTIAL RISKS AND COMPLICATIONS INVOLVED.

Name of Client

Signature

Date

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