Body Contouring Intake Form

Health Information

Acknowledgment & Acceptance

Treatment Liability Waiver

With any sort of medical procedure or treatment, there will be the risk of side effects. However, most patients report little to no side effects after they receive nonsurgical body contouring. While most side effects reported are mild, they are possible and are not limited to: redness, swelling, bruising, tingling and skin sensitivity.

Contraindications

Please advise me at the time of booking of any health conditions, allergies, injuries, recent surgeries, pregnancy or special needs which may affect your services. Some treatments are not recommended for guests who have certain conditions. For your safety we do not provide body contouring services to clients with the following conditions: Pregnant Breastfeeding HIV/AIDS Cancer Undergoing chemotherapy or immune therapy Immunodeficiency Lupus High blood pressure (uncontrolled) Diabetes (uncontrolled) Keloid scarring Excessive pigmentation Vein inflammation Prednisone and other steroid medications (treatment will increase inflammation) Chemical peels and laser resurfacing Sunburn Patients with blood clot or coagulation disorders Thyroid Disorders Patients with Epilepsy Less than 3 months post op cosmetic surgery Currently on antibiotics or steroids - schedule for a later date Currently menstruating - schedule for a later date

Cavitation

Ultrasound Cavitation is a high-power low-frequency KHz machine that has a mild ringing noise when using it. The ultrasonic cavitation treatment uses KHz frequency ultrasound to penetrate the skin and assist your body in breaking down fat cells. Multiple sessions may be required to achieve desired results at an additional cost. Ultrasound cavitation carries possible health risks and complications including but not limited to kidney failure, liver failure, pacemaker failure, birth defects, miscarriage, thyroid damage, ovary damage, hyper-tryglyceridemia, hyper-cholesterolemia, pancreatitis, infections, scarring, and/or allergic reactions to any products used during the treatment(s).

Laser Lipo

Laser Lipo (also known as lipolysisis) is a non-invasive technology that uses infrared laser light to melt fat in the fat cells. This technology offers astonishing fat and cellulite reduction results. Fat is reduced from targeted areas such as hips, flank, abdomen, waist, back, chin, under arms, legs and calves. Just imagine, a slimmer more fit and athletic appearance. The possible side effects of laser lipo include redness, swelling, heat sensitivity, pain, increased bowel movements, increased urination, increased menstrual flow and flu like symptoms.

Vacuum Therapy

Vacuum therapy increases flow of both the lymphatic and circulatory systems, and it also helps with cleaning bodily tissues. Vacuum therapy may experience discolorations that occur from the release and clearing of stagnation and toxins from my body. Discolorations will dissipate from a few hours lasting as long as two weeks. After the first time you receive vacuum therapy, you may experience flu like symptoms including but not limited to nausea, vomiting, headache, and body aches. You should avoid exposure to extreme cold, wet, and or windy conditions, hot showers, baths, saunas, hot tubs and aggressive exercise for 4-6 hours.

Radiofrequency

Radiofrequency body contouring is also called skin tightening. Radiofrequency body contouring tightens the skin, removes fat and improves tone without any downtime or pain at all. This pain-free procedure reduces cellulite, boosts collagen production and gets rid of fatty deposits that fail to go with exercise. If you have flabby skin, a post pregnancy tummy, fine lines or wrinkles, saddle bags or a sagging bum, radiofrequency body contouring is meant for you. Possible side effects include increased inflammation, redness, and rashes although these side effects are rare.

Wood Therapy

Wood Therapy assists in the breakdown of fatty deposits and cellulite. It's a non-invasive procedure with no down time. Wood Therapy entails a series of repetitive movements using wooden tools to manipulate targeted areas of muscle and fat. This treatment stimulates the lymphatic drainage system, boosts metabolism, and helps to break free toxins to be expelled from the body. You may experience mild discomfort during the procedure from the pressure and technique the technician performs and you may experience some redness, bruising, or swelling, which should subside within a week.

By signing the below, I understand that body contouring treatments are NOT recommended if I am pregnant, breast feeding, have a lymphatic disorder, acute illness or contagious disease, fever, skin disease, metal implants, pacemaker, or are currently being treated for active cancer. I have read and fully understand this agreement and all the information detailed above. All of my questions have been answered to my satisfaction and I consent to the terms of this agreement. I agree not to hold "Inscape Body" responsible or liable for any of my medical conditions that were present but not disclosed at the time of this procedure which may be affected by the treatment performed today. I understand that this activity might lead to personal injury; therefore I release Inscape Body to any liabilities like personal injury and damage.

COVID-19 Liability Waiver

Due to the outbreak of the Coronavirus (COVID-19), "Inscape Body" is taking extra precautions to help prevent the spread of this contagious disease. Please read this form entirely. We ask that our clients disclose their health history truthfully and accurately.

By signing below, I agree to the following: I and members of my household have not experienced any of the symptoms listed above within the last 14 days. I and members of my household have not traveled internationally in the last 30 days. I and members of my household, do not believe we have been exposed to someone with a suspected and/or confirmed case of the Coronavirus (COVID-19). I and members of my household, have not been diagnosed with the Coronavirus (Covid-19) within the last 30 days. "Inscape Body" cannot be held liable for an exposure to the Coronavirus (Covid-19) caused by misinformation on this form or the health history provided by each client. If I take legal action against "Inscape Body" to make a claim for damages, I shall be obligated to pay all attorney's fees and costs incurred as a result of such a claim. I hereby release and agree to hold "Inscape Body" harmless from and waive on behalf of myself, my heirs, and any personal representatives any and all causes of action, claims, demands, damages, costs, expenses, and compensation for damages or loss to myself and/or property that may be caused by any act, or failure to act of "Inscape Body", or that may otherwise arise in any way in connection with any services received from "Inscape Body". I agree to release "Inscape Body" from any and all liability for the unintentional exposure or harm due to the Coronavirus (COVID-19).