BBL Consent to Treatment Form BBL Consent to Treatment Form Please read before proceeding BBL- Brazilian Butt Lift It is a cosmetic surgical procedure that enhances the shape and size of the buttocks by transferring fat from other areas of the body, such as the abdomen, thighs, or hips. Are you are currently taking any medications or supplements? * Yes No If yes, please list. Do you have any specific skin care problems / allergies pertaining to your face or body? * Yes No If yes, please list. Have you ever had chemical peel, laser, microdermabrasion, or any skin resurfacing treatments? * Yes No Are you currently having your menstrual period? * Yes No Are you currently pregnant and/or nursing? * Yes No What skin care products do you currently use? What temperature of water do you cleanse with? (Cold, Warm, Hot) Please Read each and Click to check that you fully understand. * If I experience any pain or discomfort during the session, I will immediately inform the provider so that the products and/or technique may be adjusted to my level of comfort. * I understand that provider is not qualified to perform, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. * Because certain treatments should not be performed under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all questions honestly. * I further understand that facial should not be construed as a substitute for medical examination, diagnosis, or treatment. * I agree to keep the provider updated as to any changes in my medical profile during the session and understand that there shall be no liability on the provider's part should I fail to do so. * I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session. * I also understand that the provider reserves the right to refuse to perform treatments on anyone whom he/she deems to have a condition for which facial treatments are contraindicated. * Liability Waiver: I understand that I am using 5 n 1 40k Slim Machine and/or 9 in 1 with Laser Lipo Machine, & BBL Vacuum Therapy provided by SHAPE IT UP CONTOURING at my own risk. I agree to not hold them responsible for any complication due to the service provided as I do it of my own free will and was explained the precautions, side effects, benefits of treatment and received all pre and post care for the treatment and I choose to proceed with body sculpting session(s). * 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. * ***Brazilian Butt lift achieves the best results when the client follows the discussed treatment plan as described by the esthetician. Most treatment plans recommend multiple sessions, usually not to exceed 6-8 weeks for completion of all sessions. We cannot guarantee optimal results if you, the client is unable to attend your scheduled sessions. Body contouring plans usually involve a commitment to service by both the provider (Shape It Up Contouring) and you (the client). We try our best to accommodate unexpected schedule changes with 24-hour prior notice, but we urge you to plan your Body Contouring regimen at a time when you are able to complete your multiple sessions within the recommended time frame. * ***I further agree to provide a 24 hour cancellation notice or change of appointment time, or will forfeit a treatment off my package since treatments are by appointment only. There are not refunds on package sessions since they are highly discounted, if decide to stop treatments. Should I decide to add a treatment, that treatment will be considered an additional and separate treatment. Client Name * First Last Name * Last Email * Phone Client Signature * signature keyboard Clear Submit If you are human, leave this field blank. Δ
