My Ideal Tracker

Contact Info

First name *

Last name *

Email *

Address *

City *

State *

Zipcode *

Phone number *

Referred by

Personal

Height *

Weight *

Date of birth *

Sex *

Marital status

Number of children

Occupation

How many hours per week do you work?

Health History

*Are you currently under the care of a physician? Yes No

Please explain

* What is your motivation for wanting Body Contouring Services?

* How stressed are you? (On a scale of 1 to 10, where 10 is the worst):

Yes No * Have you ever had cancer?

Please explain

Yes No * Have you ever had any health conditions that affected your kidney?

Please explain

Yes No * Have you ever had any health conditions that affected your liver?

Please explain

Yes No * Do you have any open wounds/sores?

Please explain

Yes No * Do you have epilepsy?

Please explain

Yes No * Do you have a pacemaker or any metal plates or pins?

Please explain

Yes No * Do you have photosensitivity?

Please explain

Yes No * Are your pregnant or breast feeding?

* How much water do you drink each day?

* How much coffee do you drink each day?

Yes No * Do you exercise?

* How often?

* What type?

Yes No * Are you overweight?

* How long have you been overweight?

* How much weight do you want to lose?

Yes No * Are you embarrassed about your weight/appearance?

* Please explain

*What area(s) would you like to focus on?

Abdomen

Buttocks

Thighs

Chest

Arms

Neck

Cellulite

How important is weight or size reduction to you? (On a scale of 1 to 10, where 10 is the most important)

Yes No * Are other members of your family overweight?

Yes No * Do you feel tired, run down, or out of energy?

* Please explain

Do you experience any of the following even if they are minor and go away on their own?

High Blood Pressure

Heart Disease

Fibromyalgia

Hip/Knee Pain

Neck Pain

Digestive Problems

Numbness

Osteoporosis

Headaches

Back Pain

Arthritis

Stress/Irritability

Chronic Inflammation

Hypoglycemia

Thyroid Problems

Chronic Fatigue

Sinus/Allergy

Informed Consent and Release of Liability Form

Program and Background

You have requested treatment utilizing our LED Light Therapy equipment. This treatment is the application of specific wavelength red light, which causes fat within the adipose (fat) cell to leave and accumulate in the interstitial space. This excess fat is removed by the body’s lymphatic system and excreted without negative side effects or downtime. Any medical or cosmetic procedure carries risks, complications and varied results. The purpose of this document is to inform of the nature of this product and its risk. LED therapies have been cleared by the FDA.

Procedure

Initially you will consult with one of our therapists to determine if you are a candidate for the LED Light Therapy. You will have the opportunity to ask questions or voice concerns you may have regarding this treatment. If it is determined you are a candidate for this procedure, then paperwork, measurements, pre and post treatment photos (upon your consent) and suggested course of treatment will be given. The treatment is administered by placing LED pads on the desired area(s) to be treated. Most patients will require more than a single treatment for the Light LED Therapy to achieve its desired effect. This treatment should be used in conjunction with a healthy diet and exercise. You should consult a health care professional before beginning any new exercise program to determine if your body is physically able.

Risks/Discomfort

This treatment is non-invasive. During treatment there should be no discomfort. The client may feel the warmth of the light. LED Light Therapy is suitable for anyone over 18 who does not have any of the following issues/contraindications: Pregnancy, Breast Feeding, Recent Cancer, Heart Disease.

Benefits

LED Light Therapy has become more prominent and has been used in many studies for pain management and recently by cosmetic surgeons to emulsify adipose before liposuction with FDA clearance. The potential benefit of this treatment is body contouring without surgery. Problem areas or excess pockets of fat can be targeted, however the most commonly treated areas are the stomach, hips, flanks, and thighs. In clinical trials clients have averaged 2-5cm lost from their stomach, hips, and thighs. These results vary and no guarantee is implied or suggested that desired results will be achieved.

Voluntary Cosmetic Procedure
I understand that this is a strictly voluntary cosmetic procedure. No treatment is necessary or required and the LED Light Therapy has been chosen by me (the client).*
I have answered 'No' to the contraindications as listed above and state here that I am not pregnant nor am I breast feeding/nursing, nor do I have recent or current cancer, active kidney or active liver disease, nor do I have open wounds/sores, epilepsy or photosensitivity OR, I have answered 'Yes' to one of the contraindications as listed above, have provided an explanation of such, and still willingly consent to treatment.*
I have been informed of the potential risks and side effects of LED Light Therapy: including but not limited to redness, swelling, heat sensitivity, pain, increase bowel movements and increased urination. The risks, potential damages and adverse side effects have been explained to me and I fully understand them.*
I understand that a minimum of 9 - 12 treatments is required to achieve results at an average BMI of 25 to 30. A BMI of over 30 (which is considered in the obese range) requires a specific strategy moving forward with the minimum recommendation of 24 + treatments. Each body is different and may require more or less treatments depending on the client’s diet, exercise, metabolism and body type. I understand the treatment is most successful if I also maintain a healthy diet and commit to an exercise program.*
I know that if after the treatment program I gain weight, the results of the LED Light Therapy may be reversed.*
I understand that no guarantee has been given as to the results that may be obtained by this treatment. I have read this informed consent and certify that I understand its contents in full. I have had enough time to consider the information and feel I am sufficiently advised to consent to this procedure. I hereby give my consent to have this procedure. If at any time during the LED Light Therapy procedure I experience pain or discomfort of any kind, I agree to inform the staff immediately and/ or terminate the session at my discretion.*
I duly authorize technicians to perform the procedure for the purpose of body contouring, lymphatic drainage, improvement of cellulite and skin tightening. I am aware that clinical results may vary depending on individual factors, medical history, client compliance with pre/post treatment instructions, and individual response to treatment. If I do not make an effort to address my diet and exercise, the results achieved may not be retained.*
I have reviewed this consent form. My consent and authorization for this procedure are strictly voluntary. By signing this informed consent, I grant authority to perform the described treatment. The purpose of this procedure, risks, complications, alternative methods of treatment have been fully explained to my satisfaction. Cosmetic indications for these procedures include but are not limited to cellulite reduction, treatment of problem fat areas, skin tightening, and skin rejuvenation. Increased redness to the area for up to 12 hours may be experienced (although this is unlikely). Normal activities may be resumed following the treatment. I understand that any photos taken of me will be used to show my progress and may be used in marketing ads.*

Questions and Explanations

By signing below, you certify that this procedure has been explained to you and that you have been fully informed of the nature and purpose of the LED Light Therapy procedure, expected outcomes and possible complications, and understand that no guarantee can be given as to the final results obtained. You are fully aware that your condition is of a cosmetic concern and that the decision to proceed is solely based upon your expressed desire to do so. You are aware that LED Light Therapy may/can cause slight hypo/hyper–pigmentation of the skin and treatment is taken at your own risk (tattoo areas should be avoided). Any further questions can be directed to an LED Light Therapy Specialist.

Whole Body Vibration Plate Exercise Risks

Whole Body Vibration Plate Machines are scientifically calibrated exercise machines designed to force your muscles to stretch and contract rapidly in small increments, replicating the same action which occurs during traditional exercising. Vibration exercises use your body weight and gravity to its fullest potential. Please do not use a whole-body vibration plate or any other exercise device without getting approval from your doctor.

The device is not recommended if you are: pregnant, diabetic with complications such as neuropathy or retinal damage, have a pacemaker, recently underwent surgery, suffer from Epilepsy or Migraines, have herniated disks, spondylolisthesis, spondylolysis, have cancer or tumors, have recent joint replacements, have metal pins or plates, or have any other concerns about your physical health. These contra-indications do not mean that you are not able to use a vibration or other exercise device, but it is recommended that you consult your physician first.

I understand that using a whole - body vibration machine workout is a strictly voluntary physical activity chosen by me (the client). If at any time I experience pain or discomfort of any kind, I agree to inform the staff immediately and/or terminate the exercise.*

Privacy Policy

We value your privacy and are committed to maintaining your security and confidentiality in the use of any information you choose to share with us. We do not disclose identifiable information to any third party without your consent. Further, we do not sell, rent, or otherwise allow the unauthorized outside use of personal information such as names, addresses, phone numbers, or e-mail addresses in our database without your permission. Copies of this form and signature will be valid as if original if this document is digitally scanned. If any part of this Release is found to be invalid by the courts having jurisdiction, or becomes inoperative for any reason, such invalidity shall not affect the validity and enforceability of any other provision of this release.

Cancellation Policy

We require a 24-hour cancellation notice. I understand that if I cancel within 24 hours of a reserved session, I will lose or forfeit my session. If I fail to show up or am more than 5 minutes late, I will lose or forfeit my session due to staff wages and fees paid for my session. Our cancellation policy has been created to ensure that our loyal clients are not disturbed by the tardiness of clients who do not show up on time, or who cancel within 24 hours of an appointment.

Purchase and Reservation Policy

Sessions will only be confirmed and allowed up to the amount of pre-paid sessions. All sales are final and non-refundable. We reserve the right to terminate any client’s session, package, or contract, without refunding any monies if the client has broken any terms or policies. All purchases are final, non-refundable and non-transferable.

I understand if I have purchased and pre-paid for a first-time customer promotion, that I may not use or purchase another first-time promotion without consent. I further state that I am of lawful age and legally competent to sign this release. The procedures, alternatives and risks have been explained to me and I have been given the opportunity to ask questions. I understand it is my responsibility to inform the staff is there are any changes to my medical history.

I understand the terms herein is contractual and not a mere recital. I have signed this document of my own free act

I HAVE CAREFULLY READ, UNDERSTOOD AND AGREE TO ALL OF THE ABOVE STATEMENTS AND AM AT LEAST 18 YEARS OF AGE.*

I AGREE TO RECEIVE INFORMATIONAL AND PROMOTIONAL EMAILS FROM THE CLINIC AS WELL AS SMS APPOINTMENT REMINDERS.

Please type your name to continue*

Please make sure you complete each field, check all the boxes and spell your name exactly as it appears at the top of the form – then the submit button will appear.

Intake Form for Lean Contours

Contact Info

Personal

Health History

Do you experience any of the following even if they are minor and go away on their own?

Informed Consent and Release of Liability Form