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
Excess Facial Hair
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 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?
Do you use tanning beds and/or are exposed to the sun on a regular basis?
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
Do you have any implants?
Are you using any other skin thinning products and/or drugs that thin the blood?
List any medications, supplements, or herbal remedies you currently take:
List any known allergies or sensitivities:
Are you taking any hormones or birth control?
Do you have a menstrual period? (Female Clients)
No, due to irregular cycle.
No, due to birth control.
No, due to partial or complete hysterectomy.
Do you have irregular or painful periods? (Female Clients)
Date of last menstrual period (Female Clients)
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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 use or do you have history of using tobacco?
Yes, in the past
How often do you consume alcohol?
How healthy do you feel in general?
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
$20 Consultation Fee (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
Results are often immediate, but may be delayed in some people. While results can be really impressive, please be patient. Yes, these protocols will get you some results without eating right or exercise, but it is best to promote healthy habits and not be counter productive. As the professional, we advocate lifestyle changes to maintain results. For Best Results: A series of treatments are recommended but some individuals may require more or fewer treatments to achieve maximum results. There should be at least 1-2 days between each treatment. Eating the right types of food, exercise, and drinking 8 glasses of water per day are always recommended. For best results, it is recommended that you exercise within 4-6 hours of treatment and avoid sugar and alcohol for 48 hours after each treatment. Do you understand the above statements? Do you understand the above statements?
Precautions: Body sculpting treatments require each client to drink a minimum of half their body weight of water in ouches each day, for the 48 hours preceding the session Ex. 200 lbs./2= 100 oz. of water. This will start the process of detoxification. Body sculpting treatments are not recommended if you are pregnant, breast feeding, have a lymphatic disorder, acute illness, metal/electrical implants, pacemakers, or are currently being treated for active cancer. Treatments during menstrual cycle should be avoided. Do you understand the above statements?
By SUBMITTING THIS FORM, you agree to the following:1) I give my permission to receive massage, facials waxing services, radio frequency, cavitation, laser lipo, high frequency, detox treatments, makeup, etc..2) I understand that non of Bella DaVinci Beauty treatments and services are not a substitute for traditional medical treatment or medications.3) I understand that the Technician does not diagnose illnesses or injuries or prescribe medications.4) I have clearance from my physician to receive services Bella DaVinci Beauty services 5) 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 6) 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.7) 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.8) I understand that I or the Technician may terminate the session at any time.9) I have been given a chance to ask questions about the session and my questions have been answered. 10) I agree to adhere to all safety after care as advised by my service provider 11) I fully understand that at no time will a refund be issued and further understand that a credit maybe issued at the owners discretion. 12) I understand Bella DaVinci Beauty's 24 hour cancellation / no show policy will result in a few of up to $50 penalty or lost of a treatment from package for each violation. 13) I understand photos may be necessary for some services, and I give my permission for these photos to be used for business purposes only.
I understand and agree with all statements above
I do not agree
I certify that I have read and understand the contents of this form for Bella DaVinci Beauty services. I further agree to provide Bella DaVinci Beauty 24-hour notice of a cancellation or change in appointment time, or I will forfeit a treatment, or pay a penalty.
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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