Intake Form - New Vibe Body Wellness

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MEDICAL INFORMATION

Do you have any chronic medical conditions*

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If yes, please describe

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Do you have an allergy to any of the following?*

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Please list any medications you are currently taking, including vitamins, or put "none" below.*

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CONSENT FORM

Body sculpting increases flow of both the lymphatic and circulatory systems, and it also helps with cleaning of the tissues. The main use of body sculpting treatment is inch loss, diminishing of cellulite, and tightening of the skin.

Benefits:

Lose 1-3 inches per treatment with state-of-the-art equipment. Benefits are often immediate, but maybe delayed in some people.

For Best Results:

A series of 9-12 body sculpting treatments are recommended per each area, but some individuals may require more treatments to achieve maximum results. There should be at least 1-2 days between each treatment. This is not a weight loss treatment, but an inch loss. The inches will only return if the client goes back to their old habits. Eating the right types of food, proper exercise, and drinking 8 glasses of water per day are always recommended. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar and alcohol for 24 hours after each treatment.

Precautions:

Body sculpting treatments are not recommended if you are pregnant, breast feeding, have a lymphatic disorder, acute illness, metal implants, screws, etc., pacemakers, or are currently being treated for active cancer.

Waiver:

Should I sustain an injury while using the equipment, I agree to not hold the service provider responsible.

Acknowledgement:

I understand and acknowledge that payments for the above services are non- refundable. By my signature below, I certify that I have read and understand the contents of this Consent Form for Body Contouring. I further agree to provide 24- hour notice of a cancellation or change in appointment time, or I will forfeit a treatment off my package since treatments are by appointment only. There are no refunds if I am responding to treatment and decide to stop treatments. Should I decide to add an Ultrasound treatment and/or a Radio Frequency treatment, that treatment will be considered an additional and separate treatment. This extra treatment can be paid for separately or deducted from the number of treatments in my Cold Laser package. Should the service provider wish to use any photos of my progress other than for my personal file, I will sign a separate Photo Release form.

CANCELLATION POLICY

If there is a need to cancel for any reason, we ask for a 24-hour notice. Please understand that when you do not cancel or show up for an appointment, it is a cost to us. If you cannot provide us with a 24-hour notice, we may impose the following fees:

“No Show” for session:

*Loss of that treatment in your treatment package

Same day cancellation:

*$50.00 charge before your next scheduled treatment

I agree to the above Cancellation Policy*

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TERMS OF ACCEPTANCE / INFORMED CONSENT

Please read carefully and understand the contents of this form. Ask us if you not understand.

When a client seeks Body Contouring services and when the service provider accepts a client, it is essential that both are seeking and working for the same goals. We expect our clients to take full responsibility for their decisions to participate in any of the services/programs offered by this office.

We do not identify, diagnose, or treat ANY condition or disease. We have only one goal: TO OPTIMIZE YOUR BODY’S ABILITY TO FUNCTION NORMALLY AND OPTIMIZE YOUR FAT-BURNINGPOTENTIAL. By reducing bio-stress levels, we allow the body’s inborn self-correcting mechanism to work at maximum efficiency to restore, maintain and promote wellness.

We do not identify or diagnose any condition(s) or disease(s). We offer no treatment for any condition(s) or disease(s). We promise no cure from any disease(s) or condition(s). Instead, we facilitate your body’s own self-correcting mechanism.

It is essential that you speak to your doctor prior to making any decisions about altering any medical regimen you are currently following, changing your diet, taking supplements, or going on an exercise and/or weight loss program. Getting your doctor’s approval prior to starting any service/program at our office is critical and solely your responsibility. Should any health condition arise while you are a client, we recommend that you immediately see the appropriate health care provider.

Any options that are rendered by the staff and/or head personnel should NEVER be construed as medical advice but merely as opinions. If you like medical advice, please see one of our medical doctors. We will not deal with any medical condition.

With your acceptance below, you understand and voluntarily accept these risks and agree that neither the service provider, its staff, or any of its partners will be liable for any injury to you, including, but not limited to, personal bodily injury, death, mental injury, economic loss or any damage to you, your spouse, or relatives resulting from any act of the service provider, and its staff or anyone else using the facilities and that you acknowledge the inherent risks of the positions, movement, dietary/nutritional programs offered to and done to you at the service provider, with respect to your current or past condition(s). If there is any dispute between you and the service provider, and/or any of its staff, both parties agree to submit it to binding arbitration. We both agree to have a neutral arbitrator preside over any such dispute, not a judge or jury.

Do you agree to the above?*

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OPTIONAL PHOTOGRAPHY AND VIDEO RELEASE

I hereby grant and authorize New Vibe Body Wellness the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release New Vibe Body Wellness from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate. Invalid Input

Services to be provided*

The Office provides ultrasound, laser, radio frequency treatments, cavitation, cupping (bbl cupping), vacuum cupping with red light therapy, wood therapy, sauna blanket, vibration plate, EMSculpt and Laser Lipo. You are totally responsible to make sure you are the right candidate for the above services. All treatments are non-invasive, however, if you have any type of medical condition, consult with your physician to make sure you are a candidate for these services. Invalid Input

Payment*

Payment in full is to be made prior to the start of any program. Packages must be used within 6 months or will be forfeited. Invalid Input

Client Cooperation*

This Agreement contemplates full Client cooperation in the course of services agreed upon. This cooperation includes Client’s agreement to remain active in the recommended program for body contouring visits. The Client recognizes that compliance with recommended services and service schedule is important and the Client agrees to follow the service plan and the course of treatment agreed upon. The Client understand that lack of cooperation, failure to keep appointments and engaging activities identified by the office as potentially counterproductive to the body may necessitate additional treatments to those otherwise provided for this Agreement. Our office policy requires 24-hour advance notice for appointment cancellation. Failure to do so may result in deduction of pre-paidvisits. Invalid Input

Termination*

Subject to the provisions of paragraphs 5 and 6 of this Agreement, the Client may discontinue care and terminate this Agreement at any time by written notice to that effect delivered in person, or by mail, to the office. Such “notice of termination” shall discharge the office from all further obligations and/or duty to render care to the client. The office reserves the right to terminate this Agreement in its sole discretion notwithstanding any other terms or provisions of this Agreement. Invalid Input

No Refunds in the Event Client Terminates Agreement*

Client recognizes that neither Office personnel nor this Agreement provides a guarantee of results. The Office makes no guarantee of the extent or longevity of improvement to be expected. This Agreement deals solely with the services to be rendered and the fees to be paid for the care as provided. The Client’s payment obligation is not contingent upon the outcome of services. Client’s results can be hindered and/or suppressed by the consumption of the following, but are not limited to, alcohol, processed foods including, but not limited to, sugar-based foods and drinks, etc. It is recommended to consult your physician for dietary modification clearance if you have any questions or concerns. Invalid Input

Time Limitation for Services*

Client understands that unused visits will expire if not used within 120 days from the date Client starts the treatment unless the Office has been provided with advance notice in writing of leave of absence or other cause of delay. After 24 weeks, all outstanding services/visits will be void. Invalid Input

Release of Liability*

Client agrees to indemnify, hold harmless and release the service provider, its agents, employees, officers, directors, representatives, assigns, members, affiliated organizations, and insurers, and others acting on the Company’s behalf, of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated, and further agrees that except in the events of the Company’s gross negligence or willful and wanton misconduct, no claims, demands, legal actions and causes of action, shall be made against the Company for any economic and non-economic losses of any kind. Invalid Input

Client Responsibilities*

YOUR RESPONSIBILITIES: 1. Keep your appointments. We require 24-hour advance notice to reschedule/cancel an appointment. 2. Follow your program as closely as possible. Report any deviations to the Office staff so that we can help you get back on track. 3. If you have any challenges whatsoever, please share them with us immediately. Remember, it is in both our interests for you to succeed in achieving your goals. 4. If you have any medical conditions, please share this program with your physician immediately. The service provider is not a medical facility and does not make medical decisions. Invalid Input

Governing Law*

This Agreement shall be governed, construed and interpreted by, through and under the Laws of the State of California Invalid Input

Complete Agreement*

This Agreement constitutes the complete agreement and understanding between Client and Office and will not be changed or modified in any way unless agreed to by both parties in writing. Invalid Input

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