Universal Body Image & Laser Center
CLIENT SURVEY AND MEDICAL HISTORY
Name:
Cell Number:
Address:
Home Number:
City, State, Zip:
Occupation:
Email:
Birthdate:
How did you hear about us?
Do you have a history of or are
you currently experiencing any of
the following?
Epilepsy
Kidney/Urine Infections
Diabetes
Cancer
Hormone Replacement Therapy
Contraceptive
Autoimmune Disease
Currently Pregnant or Breastfeeding
Current Infection, Fever, or Disease
Cardiovascular Conditions
Thyroid Problems
Metal Pins/Plates/Implants
Skin issues
Digestive Problems
Circulation Problems
Gynecological Conditions
Nervous System Conditions
Y
N
Comments:
Pill/ IUD/ Other
Thrombosis/ Phlebitis/ Hypotension/
Hypertension/ Heart Disease
Dermatitis/Light Sensitivity
Constipation/ Bloating/ Gallbladder/
Stomach
Heart/ Blood Pressure/ Fluid
Retention/ Varicose veins
Irregular Periods/ PMT/ Menopause
Migraines/ Tension/ Stress/
Depression
Immunodeficiency Disorders
HIV
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List any medical condition(s) currently being treated by a practitioner:
List all medications, vitamins, and supplements that you are currently taking:
List any known allergies:
List any previous laser procedures:
Area interested in treating:
2
Universal Body Image & Laser Center
TREATMENT AGREEMENT AND CONSENT FORM
I, _________________________, duly authorize the technicians of Universal Body
Image to perform the iLipo and/or the Lipo-Light procedure(s) for the purpose of spot fat
reduction / improving the appearance of cellulite. I am aware that clinical results may
vary depending on individual factors, including, but not limited to, medical history, client
compliance with pre/post treatment instructions, and individual bodily response to
treatment. I have been made aware that my diet and the amount of exercise I do, will
have a major effect on the results of my treatments. If I do not make an effort to address
my dietary requirements and exercise, I am aware that the results achieved may not be
retained.
I understand that laser body contouring involves a course of treatments and all sales
are final. Services and treatment packages are non-refundable and non-transferable.
The fee structure has been fully explained and I understand that I am required to pay for
a course of treatments prior to any procedures taking place. I am fully aware that should
I wish to cancel the course, the outstanding treatment value is non refundable. For your
convenience, we accept cash, Visa, Maser Card, and American Express.
The course cost is $_________________ for _________________ treatment sessions.
Individuals with any of the following conditions are not candidates for treatment with any
of our body contouring lasers. Contraindications include:
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Pregnancy
Epilepsy
Uncontrolled Thyroid Gland Dysfunction
Uncontrolled Hypertension
Cardiac Arrhythmias or Heart Disease
Pacemakers
Recent or current history of cancer, or actively undergoing radiation or
chemotherapy
Liver/Kidney Disease
Photosensitivity to 650 ~ 660nm of light
Immuno-suppressed disorders
Current Infection (including viral)
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I understand that with some skin types, there is a risk of temporary redness and/or
discoloration of the skin localized in the treatment area that can last up to several hours.
There is also a possibility of tattoo lightening if located in the treatment area.
I certify that I have been fully informed of the nature and purpose of the procedure,
expected outcomes, and possible complications. I understand that no guarantee can be
given as to the final result obtained. I am fully aware that my condition is of a cosmetic
concern and that the decision to proceed is based solely on my expressed desire to do
so.
I understand that it is my personal responsibility to inform the laser technician of the
clinic named above of any changes to my medical history during the course of laser
body contouring treatment sessions. I confirm that should this occur, I shall advise the
technician of any changes.
I certify that I have been given the opportunity to ask questions, any questions have
been answered to my satisfaction, and that I have fully read and understood the
contents of this consent form.
Client Signature:____________________________________________________
Date:_____________________________________________________________
Staff Initials:_____________
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Universal Body Image & Laser Center
i-Lipo and Lipo-Light
Pre/Post Treatment Instructions:
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Avoid eating two hours before and after treatment sessions
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Avoid heavy meals on the treatment days
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Drink plenty of water to facilitate lymphatic drainage
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Limit carbonated drinks, coffee, and tea during treatment period
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Avoid fasting or the body will go into “starvation mode” and become more
resistant to the release of stored fat
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Within the two hours following a treatment, the client MUST perform 30-45
minutes of cardio-vascular work-out in order to create the energy demand that
will facilitate metabolism of the fatty acids and glycerol freed from the fat cells
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Consider contraindications or other medical issues that may impact the results of
this “one off” treatment. Some medical disorders that may reduce first treatment
response include thyroid, immune, lymphatic related conditions, pre-menopause,
menopause, diabetes, and infection (including viral)
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Wear clothing that will facilitate the laser pad placement in the treatment areas
I certify that I have been counseled in the pre and post treatment instructions and have
been given a copy of them. I have read and understand the instructions and realize that
I must follow these instructions diligently in order to obtain optimum results.
Client Signature:_______________________________________________________
Staff Initials:_____________
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Universal Body Image Fitness Center
LIABILITY WAIVER
I, __________________________________, acknowledge that I will be engaging in
unsupervised activities in the UBI Fitness Center which may lead to personal injury. I
agree to assume all responsibility for any personal injury that may occur. I hereby
authorize UBI staff to act on my behalf, if I am unable to do so, to the best of their ability
in an emergency requiring medical attention. I assume personal responsibility for any
damages that may result from an injury. I furthermore agree not to hold UBI responsible
for any injury that might occur during my participation in all activities associated with
fitness training performed in the UBI facility.
Client Signature:____________________________________________________
Date:_____________________________________________________________
Staff Initials:______________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name:____________________________________________
Emergency Contact Phone Number:_____________________________________
Relationship to Client:________________________________________________
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New Client Form: Body Sculpting