BODY SCULPTING INTAKE FORM

Before your scheduled appointment please drink 4-6 bottles of water. The more water you drink the better your results will be.

First name

Last name

Phone

Message

Do you have any chronic medical conditions that we should know about?

Are you currently taking any medications?

Do you have type 1 or type 2 diabetes?

Do you have high blood pressure?

Have you had cancer in the past 12 months?

Do you currently have cancer? If yes, are you currently on chemotherapy?

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, or hormonal pellets? If yes, please list...

Do you have any known kidney or liver disorders?

Are you currently pregnant or nursing?

When was the first day of your last menstrual cycle?

Body Sculpting Terms & Conditions

Day of appointment:

Prior to starting your first session and during each 3-day period of treatment, we recommend you to drink 2-3 liters of water. Water and hydration are key to this process being effective.

To maximize the effectiveness of your sessions, it is best to restrict products that impact lymphatic flow during the program. (caffeine, alcohol, and sugar in large amounts)

we recommend eating a healthy diet to stabilize the fat and inches loss you obtain during the program.

Always consult with your physician before beginning any Health & Diet program

Always inform us if you have change in health status or experience any unusual symptoms during the program.

We recommend additional daily exercise to stimulate lymphatic flow. This includes low impact workouts: brisk walks, swimming, or cycling during this process. Adding this activity to your ongoing lifestyle will help to stabilize your weight and fat loss.

We concentrate on one body part at each session. Treatments can be done a minimum of 72 hours apart.

After care instructions must be followed explicitly, whether given in writing or orally. Failure to follow after care instructions may compromise the final results of the treatment.

Before, during and after pictures or videos may be taken to document the treatment. these pictures of videos become Jb Esthetics sole property and may be used for its legitimate business purpose.

All costs are payable in full on the day of your appointment. Rescheduled appointments less than 24 hours will lead to loss of deposit & remainder balance will be charged in full. Clients who do a No call No show will be charged the remaining balanced with the card on file. To secure a new appointment date a new deposit fee must be paid again. All payments made after treatments are non refundable as well as the deposits paid to secure appointments.

Packages (3 or more sessions) is payable in full at the first scheduled appointment. Packages once purchased with first initial visit are non- refundable. Appointments can be scheduled a maximum of 3 times.

I have read and agree to the terms above.

COVID-19 Pre-Screening

Are you currently waiting on the results of a COVID-19 test?

Yes

Have you experienced any of the following symptoms in the past 48 hours:

Have you had any signs of a fever in the past 24 hours or had a temperature that has elevated 100.0F or greater?

Yes

Within the past 14 days, have you been in close physical contact with anyone who test positive with cov-19?

Yes

Identification

This is required, this is for your protection and mine.