Consent Form | Mariannas Beauty Sal

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Mariannas Beauty Salon

Body Cavitation Consent Form

First name*

Last name*

Email*

Phone*

Birthday*

Day

Month

Year

Do you have any chronic medical conditions that we should know about?*

Yes

No

Are you currently taking any medications? *

Yes

No

If you ticked ‘Yes’ in the previous question please list down the medication you’re taking.*

Do you have any allergies? *

Do you have type 1 or type 2 diabetes?*

Yes

No

Do you have any known kidney or liver disorders?*

Yes

No

Do you have photosensitivity to sun exposure?*

Yes

No

Do you currently have cancer?*

Yes

Yes + Chemotherapy

No

Have you had cancer in the past 12 months?*

Yes

No

Are you pregnant?*

Yes

No

Im not sure

Do you have high blood pressure?*

Yes

No

Do you have any cardiovascular conditions?*

Yes

No

Do you have any medical devices implanted including, but not limited to, hearing aids, a pacemaker, IUD or hormonal pellets?*

What concerns would you like addressed today?*

Do you want to lose body fat?*

Yes

No

What area would you like your treatment to focus on?*

How many areas did you select for your treatments booking*

1

2

3

Do you want to tighten skin on your selected area?*

Yes

No

Do you want to reduce cellulite on your selected area?*

Yes

No

Please list your regular exercise habits:*

Please describe your current dietary habits:*

How many liters of water do you drink daily?*

Date*

Day

Month

Year

By ticking the checkbox, I agree to the following:

I have completed this form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I agree and understand to waive all liability toward myself for any injury or damages incurred due to any information I have provided that had a misrepresentation of my health.

Please complete this form before booking your cavitation treatment. This will help us ensure that the treatment is suitable and safe for you. Your health and safety are our top priorities, and this information will allow us to provide you with the best care possible. Thank you for your understanding!

Mariannas Beauty Salon

07510778847

bookings@mariannasbeautysalon.com

Oakfield Gardens

N18 1NX

London

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