Waiver

This release and waiver will cover all of our services: The FIT Bodywrap®, the YOLO Curve Lipo Laser and the Cocoon Fitness Pod. Please fill out the entire form, even if you only plan on receiving one of the treatments.

Client Name

Date of Birth

Phone Number

Email Address

Street Address

City

State

Zip Code

Emergency Contact

Emergency Contact Phone

Relationship

Do any of the following apply to you?*

Cardiac Condition
Implanted Pacemaker
Blood Thinning/Clotting Disorder
Anemia/Menorrhagia
Hemophilia
High or Low Blood Pressure
Hyper/Hypo Thyroid
Multiple Sclerosis

Lupus Erythematosus
Adrenal Suppression
Kidney Malfunction
Diabetes Requiring Insulin
Artificial Joints/Implants or Metal Pins/Rods
Acute Joint Injury
Enclosed Infection (Dental, Joint)

Open Wounds
Skin Diseases
Contact Allergies
Fever
Severe General Infection
Pregnancy
Any other health issue or concern

Yes

Release of Liability

This release and waiver is entered into by the client and provider, Skin Tight Body Contouring, effective on the date this form is submitted. In consideration of Provider permitting Client to receive FIT Bodywrap® sessions (“FIT Bodywrap® session”) at Provider, Client agrees as follows:
Representation of Ability to Participate. Client represents that he or she is of legal age and in satisfactory physical condition and has no medical condition that would prevent Client from receiving a FIT Bodywrap® session. Client affirms he or she is properly hydrated and he or she has had the opportunity to inspect the facility, learn about the FIT Bodywrap® session, and ask any questions he or she may have regarding the FIT Bodywrap® session. Client affirms he or she has had the opportunity to consult his or her physician about any unique needs or restrictions Client may have prior to receiving a FIT Bodywrap® session. In the event of an accident, and at Client’s expense, Client hereby authorizes medical transportation to a medical facility.
Acknowledgement and Assumption of Risks. Client acknowledges he or she is aware a FIT Bodywrap® session involves an infrared heat body wrap and may require physical exertion that may be strenuous and may cause physical injury. Client acknowledges that he or she is fully aware of the risks and hazards involved. Client fully accepts and assumes all such risks and all responsibility for losses, costs, and damages that may result from a FIT Bodywrap® session.
Release. Client hereby releases, acquits, covenants not to sue and therefore discharges Provider, its owners, officers, administrators, employees, instructors, and/or agents, as well the owners, distributors, manufacturers, wholesalers, and any other entity affiliated with FIT Bodywrap® (collectively “Released Parties”) of and from any and all actions, and knowingly, voluntarily, and expressly waives any claim Client may have against the Released Parties for any injuries or damages (known or unknown), property damage or loss of any kind, whether such injury, damage, or loss was caused by the alleged negligence of Provider, another client, or any other person or cause, which Client may sustain as a result of receiving a FIT Bodywrap® session.
Indemnification. Client further voluntarily defends, indemnifies, and holds harmless the Released Parties from any and all liabilities or claims made as a result of or relating to Client receiving a FIT Bodywrap® session, including attorney’s fees, for any accident, injury, illness, loss, damage to person or property, or other consequences suffered by Client or any other person arising or resulting directly or indirectly from Client receiving a FIT Bodywrap® session, whether such injury, loss, or damage was caused by the alleged negligence of Provider, another client, or any other person or cause.
Severability. Client further expressly agrees that the foregoing Release and Waiver is intended to be as broad and inclusive as is permitted by the laws of the United States, and the state in which it is signed, and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
Client affirms he or she has been fully informed and understands the use of a FIT Bodywrap® session, has prepared for the FIT Bodywrap® session as indicated, and accepts personal responsibility for his or her session. Client is aware that the results achieved by this FIT Bodywrap® session may vary from person to person, and Client acknowledges that no promises or guarantees have been made to Client as to the results of this session. Client understands Provider does not diagnose conditions or illnesses.
This Release and Waiver is governed by the laws of the State of California, and exclusive jurisdiction shall be in San Diego County, California. This Release and Waiver shall be binding on the Client’s assignees, heirs, next of kin, executors, and personal representatives.
Before, during, and after a FIT Bodywrap® session it is imperative to stay hydrated.
You may not participate in a FIT Bodywrap® session if you are under the legal age in your jurisdiction.

Doctor Approval Needed

Please contact us at (585)732-7166. You should NOT receive a FIT Bodywrap® session without approval from your doctor if you suffer from any of the conditions described above, any other condition where the use of an infrared heat session is contraindicated, or if you are taking prescription medication. If any of the above listed items apply to you, please consult your physician and obtain written approval prior to receiving a FIT Bodywrap® session.

By clicking NEXT, you affirm that none of the contraindications listed above prevent participation in receiving a FIT Bodywrap® session, and you certify that you have carefully read and understood the contents of this release and waiver. You are executing this form voluntarily and with full knowledge of its significance.

I confirm the following:

I am not pregnant or lactating
I do not have epilepsy
I do not have a pacemaker
I do not have Herpes Simplex
I do not have uncontrolled Hypertension
I have no known liver or kidney disorders
I have no know thyroid gland dysfunctions
I do not have a compromised immune system
I do not have cancer or a history of cancer
I have no known photosensitivity to sun exposure I am not taking drugs that cause photosensitivity

Yes

I understand the following treatment limitations and risks:

I must be over the age of 18
I understand there are no guarantees as to the results of this treatment.
I understand that to achieve maximum results, I may require several treatments.
It has also been recommended to achieve optimum results, I understand that an appropriate diet and regular exercise will assist to sustain and create accumulative degree of overall spot fat reduction and body contouring.
I understand that the YOLO Curve is approved for Pain Management and is used as an off label application for spot fat reduction and body contouring (the YOLO Curve is however approved for body contouring in Europe and Canada).
I have been informed and I understand that temporary hyperpigmentation / hypo pigmentation on rare occasion may occur as a result of treatment.

Doctor Approval Needed

Please contact us at (585)732-7166. You should NOT receive a YOLO Curve laser session if any of the above applies to you. Please consult your physician and obtain written approval prior to receiving laser treatment.

Yes

Acknowledgment and Understanding Required

Please call us at (585)732-7166 before proceeding so that we may discuss any questions or concerns. In order to receive laser treatment, it is vital that you understand and agree to all of the limitations and risks.

YOLO Curve Treatment Disclaimer

The Curve is a new and innovative technology that has been cleared for spot fat reduction and body contouring.
The Curve is one of the tools that we can use to help you reach your goals and the real advantage of this technology lies in the fact that we can specifically target a trouble area. Once the fats have been released from the cell they can be used by the body as a fuel source. It is therefore critical that the dietary and lifestyle changes are made to help support the goals of treatment.
A reduced calorie diet and an exercise program that will help to burn approximately 350 – 500 calories post treatment are ideal. Individual results may vary and it is the responsibility of the client to ensure they are doing the appropriate home care to ensure maximum results. Clients should be consuming a caloric intake equivalent to their target weight (lbs) multiplied by 10. For example a 220lb male who wants to reach 200 lbs should be consuming a daily intake of 2000 calories. In some cases additional support may be required for lymphatic drainage to help stimulate the body to clear the fats that are released from the cell. Most clients experience a ½ inch reduction with each treatment and multiple inches can be lost with a series of treatments.

Patient Agreement

In submitting this agreement I understand that I am beginning a series of treatments to help reach my goals of body contouring and spot fat reduction. I understand that individual results may vary and that I must commit to changing the dietary and lifestyle factors necessary to achieve optimal results. I understand that the first step to a positive change is creating awareness about the steps necessary to reach these goals, and will work diligently to ensure success.
I understand that much of the success of the program will depend on my efforts and that there are no guarantees or assurances that the program will be successful. I realize there may be pre-existing medical conditions that can preclude me from seeing optimal results. By submitting this agreement, I release the spa/clinic, manufacturer and distributors from any liability regarding this treatment and do so understanding that results can vary from one individual to the next.
I have read and fully understand this consent form and I realize I should not submit this form if all items have not been explained to me. My questions have been answered to my complete satisfaction. I have been urged and have been given all the time I need to read and understand this form. If I have any questions regarding the risks or hazards of the proposed treatment, or any questions whatsoever concerning the proposed treatment or other possible treatments, I will ask my doctor now before submitting this consent form.

Ensure Your Best Results

Welcome and Congratulations! This is an important decision towards improving your wellness and overall lifestyle! We share the mutual desire of you reaching all of your wellness goals involving the YOLO Curve. In order for you to reach these goals, we have provided a few points to educate you on achieving your best results. It is important to manage your expectations according to an appropriate diet, lifestyle and exercise program incorporated in conjunction with your LipoLaser treatment protocol:
Avoid consuming large amounts of water prior to treatment(s)
• Don’t eat 4 hours prior to treatment(s)
• Drink plenty of water after every treatment
• Incorporate Whole Body Vibration (WBV) post treatment for 10 minutes or ensure you undertake physical activity following each treatment to maximize your results
• Manage caloric intake; excess calories will counteract the laser treatments
• Alcoholic beverages and high sugar content drinks must be avoided before and after treatment(s)

Consent For Treatment

My submission of this form herein constitutes my acknowledgment that I am a competent, consenting adult of at least 18 years of age (or my parent or legal guardian is giving consent on my behalf), and further, that I:
• Have read and understand the information provided in this form
• Have had my procedure adequately explained to me by my clinician/Doctor
• Have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction
• Have received all of the information I desire concerning my procedure
• Understand all post treatment recommendations and agree to adhere to them
• Freely assume any risks of complications or injury from known or unknown causes associated with, relating to, or otherwise arising out of this procedure
• Have the right to consent to or refuse any proposed procedure at any time prior to its performance
• Must notify the clinician if my medical history changes prior to subsequent treatments
• Consent to photographs of the treatment area

By clicking NEXT, you affirm that none of the health contraindications listed above prevent participation in receiving a YOLO Curve session, and you certify that you have carefully read and understood the contents of this release and waiver. You are executing this form voluntarily and with full knowledge of its significance.

Are you currently pregnant or breastfeeding?*

Yes

What medications are you currently taking? Please list all prescriptions, over-the-counter, vitamins or supplements:*

Allergies: If you are allergic to any medications, please list them along with your reactions. If none, please indicate.*

Are you currently being treated for any medical conditions? Please indicate yes or no. If yes, explain:*

Do you have any of the following conditions?

Heart/respiratory problems
Pacemaker
High blood pressure
Kidney disorders
Nervous conditions (e.g. epilepsy)
Diabetes
Pregnancy / Breastfeeding
Implants
Open lesions
Pustules or cysts

Yes

**The above conditions mean we advise you do NOT receive the Cocoon System session. However, you may bring a medical release prior to your session if you still want to continue at your own risk.

By clicking SUBMIT, you confirm that the answers to this questionnaire are true and correct. You have read the contents of this personal profile, health history, and consent form carefully and state that you are not aware of any medical conditions or any other reason that would prohibit you from receiving Cocoon sessions. You understand individual results may vary. You have been given instructions for the proper use of the equipment and you will use it at my own risk. You hereby give consent to have Cocoon sessions and release the owners, operators, and manufacturer from any damages that you might incur due to the use of this facility.