Intake Form for Lean Contours

Contact Info


Health History
*Are you currently under the care of a physician?
* Have you ever had cancer?
* Have you ever had any health conditions that affected your kidney?
* Have you ever had any health conditions that affected your liver?
* Do you have any open wounds/sores?
* Do you have epilepsy?
* Do you have a pacemaker or any metal plates or pins?
* Do you have photosensitivity?
* Are your pregnant or breast feeding?
* Do you exercise?
* Are you overweight?
* Are you embarrassed about your weight/appearance?

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

* Are other members of your family overweight?
* Do you feel tired, run down, or out of energy?
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

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.


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.


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.


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

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.

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