Bella DaVinci Beauty
Body Sculpting and Wellness Spa New Client Consultation Form
Client's Date of Birth
What is your Gender?
How did you hear about us?
Areas of Concern
Treatments of Interest
Non Surgical Lipo
Cellulite Reduction Therapy
Brazilian Butt Lift Package
Foot Detox Bath
Non Surgical Facelift
Hair Loss Replacement
Infrared Sauna Detox
V-Tox (vaginal steaming)
Have you ever received any of these services professionally:
Surgical Cosmetic Procedure
Non Surgical Body Sculpting
Non Surgical Facelift
Hair Loss Replacement
Infrared Sauna Detox
Please enter Your Weight and Height
Please select any condition(s) a physician has diagnosed you with:
A Lymphatic Disorder
High Blood Pressure
Low Blood Pressure
Herpes, Hepatitis, HIV/AIDS
Phlebitis / Varicose Veins
Check any symptoms that you have experienced in the PAST WEEK
Unexplained change in weight
Shortness of breath
Chest pain, pressure or tightness
Swelling of hands/feet/ankles
Constipation or diarrhea
Stiffness/Pain in joints/muscles
Difficulty urinating/Night-time urination
Urinary incontinence (leakage)
Sexual Difficulties/Painful intercourse
Feelings of Guilt
Insomnia/Problems with Sleep
Loss of energy
Thoughts of harming self or others
Menstrual Cycle Issue(s)
Are you experiencing any pain?
Pain in Temples
Pain At Top of the Head
Pain in Eyes
Pain in mouth
Pain at base of skull
Pain in entire head
Pain Moving Head
Ringing in the ears
Stiffness in Neck
Neck Out of Place
Muscle Spasms in Neck
Gliding or Grating Sound with Neck Movement
Pain in Left Shoulder
Pain in Right Shoulder
Can't Raise R. Hand above Head
Can't Raise L. Hand Above Head
Stiffness in Shoulder
Stiffness in Arms
Stiffness in Hands
Stiffness in Legs
Stiffness in Toes
List any known allergies or sensitivities:
Do you have any implants?
Are you taking any hormones or birth control?
Are you using any skin thinning products and/or drugs that thin the blood?
List any medications, supplements, or herbal remedies you currently take:
How healthy do you feel in general?
Excess Facial Hair
Do you have a skin care regiment?
Have you used any Alpha Hydroxy Acids (AHA) or glycolic products in the past 48-72 hours?
Have you used Retin-A, Renova, or Accutane within the past year? If so, when?
Describe your body type according to the pictures above
Sagging Skin on all over
Sagging Skin on arms
Sagging Skin on breast
Sagging Skin on abdomen
Sagging Skin on buttock
Sagging Skin on legs
Sagging Skin back
Cellulite on buttock
Cellulite on thighs
Cellulite on calfs
Scar tissue on face
Scar tissue on arms
Scar tissue on chest
Scar tissue on breast
Scar tissue on abdomen
Scar tissue on back
Scar tissue from C-section
Do you use tanning beds and/or are exposed to the sun on a regular basis?
What is your occupation?
How many hours do you work weekly?
Please list any and all piercing you have.
Please list any and all tattoos you have and where it is located.
Have you traveled within the past 30 days?
If yes, where and when?
Do you drink water daily?
Yes, 1 to 2 bottles daily
Yes, 3 to 4 bottles daily
Yes, 5 to 6 bottles daily
Yes, more than 8 bottles daily
No, I do not drink water regularly
No, I do not drink water at all
Do you eat breakfast?
Yes, before 8am
Yes, between 8am and 10am
No, I do not eat breakfast
Do you currently follow any specific diet system?
If yes, please list if current or past and the name of the diet system.
Please select any options that apply the way you commonly eat.
I cook most my meals at home during the week
I eat fast food a lot during a lot during the week
I eat out at restaurants a lot during the week
I eat a lot of oily/fried foods
I eat red meat, pork, chicken
I do not eat any meat and/or animal products
I eat a lot of fruits and vegetables
I eat a lot of candy and sweets
How often do you consume alcohol?
Do you use or do you have history of using tobacco?
Yes, in the past
Female Clients Only
Female Clients Questionnaire
Are you currently on your period?
Do you currently have fresh spotting?
Have you had spontaneous heavy bleeding within the past 3 months?
Have you had two periods per month (i.e. a period every 2 weeks) in the past 3 months?
If trying to conceive are you past ovulation or IUI/IVF transfer?
Are you trying to conceive?
Do you have any yellowish, greenish, or brown discharge?
Have you noticed a Vaginal ordor?
Do you have an infection characterized with a burning itch?
Do you have tubal coagulation (burning of the fallopian tubes through laparoscopic surgery through the belly button)?
Do you have a birth control arm implant (i.e. nexplanon)?
Have you had a uterine ablation procedure (where the uterine walls are burned so they scar over)?
Do you have an Essure insert?
Are your menstrual cycles currently or historically ever 27 days or shorter?
Are you currently using an IUD?
Do you currently have or have a history of being prone to yeast infections?
Do you currently have or been prone to bacteria vaginosis?
Do you have the nuva ring in? (If so, it should be removed prior to steam session)
Do you have vaginal dryness?
Do you have a menstrual period?
No, due to irregular cycle.
No, due to birth control.
No, due to partial or complete hysterectomy.
Do you have irregular or painful periods?
Date of last menstrual period
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Consultation Fee/ Appointment Deposit (REQUIRED FOR ALL NEW APPOINTMENTS)
( X )
$20 Consultation Fee/Appointment Deposit (required for all new appointments including Groupon clients, non refundable, if applicable will be applied towards any service or package purchased.)
Credit Card Number
Disclosure & Consent
Please Read and Sign
I understand drinking my recommend daily water intake is not only essential to my health, image, and wellness goals, it is a requirement for most services and all body sculpting services. Please select your recommend daily water intake according to your weight from the list below.
Because my weight is less than 135lbs I should drink at least 67.5oz or (4) 16.9oz bottles of water daily.
Because my weight is between 136lbs and 203lbs I should drink at least 101.5oz or (6) 16.9oz bottles of water daily.
Because my weight is between 204lbs and 270lbs I should drink at least 135oz or (8) 16.9oz bottles of water daily.
Because my weight is between 271lbs and 340lbs I should drink at least 170oz or (10) 16.9oz bottles of water daily.
Because my weight is between 341lbs and 410lbs I should drink at least 205oz or (12) 16.9oz bottles of water daily.
Because my weight is between 411lbs and 475lbs I should drink at least 235oz or (14) 16.9oz bottles of water daily.
If a product patch test is advised or desired for service, would you like to schedule your patch test at least 24 hours before your appointment or waive the patch test?
Yes, I would like to schedule a patch test at least 24 hours before my appointment
No, I would like to waive the patch test
I would like more information
I give my permission to receive massage, facial, waxing services, radio frequency, cavitation, laser lipo, high frequency, detox treatments, makeup, etc.
I do not agree
I understand that BEFORE, DURING, AND AFTER photos maybe necessary for some services, these photos become the property of Bella DaVinci Beauty and maybe used for business purposes only. We will ensure that every effort is made to conceal any and all identifying body marks, tattoos and piercings to help protect your identity.
I understand and agree with the above statements
I do not Agree with the above statements
I understand that I or the Technician may terminate the session at any time. I have been given a chance to ask questions about the session and my questions have been answered. I fully understand that at no time will a refund be issued and further understand that a credit maybe issued at the owners discretion.
I understand and agree with all statements above
I do not agree
I understand that Bella DaVinci Beauty treatments and services are not a substitute for traditional medical treatment or medications. I understand that the Technician does not diagnose illnesses or injuries or prescribe medications. I have clearance from my physician to receive services Bella DaVinci Beauty services. I understand the risks associated with Bella DaVinci Beauty services include, but are not limited to: Superficial bruising or redness, Short-term muscle soreness, Exacerbation of undiscovered injury. I understand the importance of informing my Technician of all medical conditions and medications I am taking, and to inform about any follow up. I understand that there may be additional risks based on my physical condition. I understand that it is my responsibility to inform my technician of any discomfort I may feel during the session so he/she may adjust accordingly.
I understand and agree with all the statements above
I do not agree with the statements above
Some Bella DaVinci Beauty services and all Body sculpting treatments are a process and subsequent visits may be necessary in order to achieve the desired results. Subsequent visits are subject to additional charges per visit which depends on the amount of work needed. Actual results vary from person to person and Bella DaVinci Beauty does not guarantee any specific result. The Ultrasound Cavitation treatment carries with it possible health complications and consequences, which include but not be limited to the risk of kidney failure, liver failure, pacemaker failure, birth defects, miscarriage, thyroid damage, damage to ovaries, lactation complications, hyperglycemia, hypercholesterolemia, pancreatitis, infection, scarring and or an allergic reaction to any products used, excessive thirst, dehydration, nausea, and bruising. The Ultrasound Cavitation treatment includes, but is not limited to, the use of high power low frequency Ultrasound Cavitation which uses 25 Khz to 40 Khz frequency ultrasound to penetrate the skin and assist with the breakdown of fat cells by creating micro bubbles that increase the pressure around the adipocyte and forces it to implode, thus breaking down the adipocyte’s cell membrane. Radio Frequency is the controlled, radio frequency heating of deep skin with cooling on the surface skin. It is a recent new technology, which heats the underlying skin to eliminate wrinkles, promoting new collagen formation, elasticity improvement, cellulite therapy and fat cell destruction. Ilipo Lite is an application of a 650nm-660nm low intensity laser, which has been shown through extensive research to cause the triglycerides within the fat cell to break down into free fatty acids and glycerol and release them through channels in the fat cell. The fatty acids and glycerol are then transported to the body by the lymphatic system, to tissues that will use them during metabolism to create energy. AFTERCARE: Aftercare instructions have to be followed exactly, whether given in writing or verbally. Failure to follow aftercare instructions may compromise the final results of the treatment. Instructions: You should avoid alcoholic beverages, and drink a minimum of half your body weight of water in ounces daily. RELEASE: I recognize that there are certain inherent risks associated with the above described treatment and I assume full responsibility for personal injury to myself. In exchange for such treatment, I hereby fully release Bella DaVinci Beauty (including it’s employees) from any and all damages, costs, expenses, liabilities, cause of action, claims and demands of whatever character in law or equity, whether known or unknown, direct or indirect, asserted or unasserted, and whether or not in account of myself or Bella DaVinci Beauty or other third parties, or in any way arising out of the above described treatment I have requested Bella DaVinci Beauty to perform. It is the intention of the parties, that this agreement binds all parties who’s claims may arise out of, or relate to the treatment services provided to Bella DaVinci Beauty, including any spouse or heirs of the client/patient, and any children, whether born or unborn. Any legal or equitable claim that may arise from participation shall be resolved under Virginia State Law.
I understand that: how to prepare for my service(s), aftercare instructions, and frequently asked questions are available on the BellaDaVinciBeauty.com website in addition to any directions given to me by my technician. I understand that BELLA DAVINCI BEAUTY HAS A STRICT NO REFUND POLICY and that a credit maybe issued at the discretion of the owner. I certify that I have read, understand, and agree the contents of this form for Bella DaVinci Beauty services.
I do not agree
By signing this agreement, I have voluntarily elected to receive non surgical, non invasive, cosmetic and/or wellness services and treatments. I understand services and treatments are preformed and overseen by a Commonwealth of Virginia Licenced Cosmetologist, and within the scope of practice set forth by the Virginia Department of Professions and Occupational Regulations. By signing this agreement I confirm that I am over the age of 18, I understand that most Bella DaVinci Beauty treatments stimulates permanent changes, that such treatments has possible adverse consequences and that the treatments are for cosmetic purposes only. I certify that I have read the above paragraphs; received, read, and agree with statements indicating I do not have any contraindications; and fully understand this consent and procedure form and herby consent to the indicated procedure(s). This means that I accept full responsibility for these and/or any other complications which may arise or result during or following treatment, which is to be performed at my request according to this agreement and I herby agree to arbitration of any malpractice claim. I further understand and agree with all statements included with in this form by signing this agreement below.
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Female Clients Only
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