Harmony Sculpt
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Consent Form
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Customer Information
Name
*
First
Last
Email
*
Phone
*
How old are you?
*
Must be 18 years old.
Emergency Contact Information
Name
*
First
Last
Phone
*
Health Issues
Do you have any of the following issues?
*
Cardiac or Vascular issues
Diabetes
Epilepsy
Acute illness
Comprimised liver function
Severe bleeding tendencies
Carry a pacemaker
Cancer
Kidney (Gall-stone)
Comprimised immune system
No, I do not
Do you have photosensitivity to sun exposure or are you taking any drugs that cause photosensitivity?
*
Yes
No
Do you have any of these skin conditions?
*
Herpes
Sores
Psoriasis
Eczema
Freshly Tanned Skin
No, I do not
Do you have a metal or copper IUD?
*
Yes
No
If yes, doctor's note may be required
Are you on your menstrual period?
*
Yes
No
Acknowledgments
Terms and Conditions
*
I agree with Harmony Sculpt Terms listed below
- I understand that this procedure cannot guarantee 100% expected results and that several treatments might be needed to achieve good results.
- I allow Harmony Sculpt to take photographs, videos, and measurements of my before and after results as proof of the treatment and give permission to use these materials for advertising, marketing, or educational purposes.
- I confirm that all information provided in this form is accurate and true to the best of my knowledge.
- To achieve optimum results, I understand that maintaining a healthy diet, lifestyle, and regular exercise will support the outcomes I am seeking.
Service Policies
*
I have read and agree with Service Policies.
View Service Policies
Signature
*
Clear Signature
By signing this agreement, I acknowledge and accept that results from the treatment(s) provided by Harmony Sculpt may vary from one individual to another. I release Harmony Sculpt from all liability related to these treatments. I understand that achieving my personal body goals through body contouring requires commitment to positive lifestyle changes. To ensure the success and longevity of my results, I agree to adopt and maintain healthy habits, working in harmony with the treatment(s) provided.
How on skin
Signed Date
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