TLC BUTTERFLY EFFECT SPA LLC COOLSCULPTING CUSTOMER CONSENT FORM AND RECEIPT

 
 
 
Name *
Name
Address *
Address
Phone *
Phone
Healthy heart is required for this procedure and NO metal instruments can be present during these scheduled treatments. Please see your medical professional before beginning any services if you any heart paces, uncontrollable high blood pressure and or cancer/radiology treatments within 30-days of this treatment. There is a $45 Consultation Fee required in order to complete your procedure.
Have you ever done Cold Fusing? *
Have you suffered any frost bite on any part of your body? *
Have allergies or reactions to any latex or oils? *
Have you recently had any type of cosmetic surgery? *
Are you pregnant, suspect you’re pregnant or breast feeding *
Under the age 18? (Requires Parent Consent) *
I, (the client/consumer), hereby declare that I am 18 years old or am the parent/legal guardian of the client/consumer is under the age of 18 did in fact consult with our dental professional within the last 30 days before using this self-administered over the counter teeth whitening product and or service. Furthermore, in consideration of the product, light source, service provide and other good and valuable consideration of information received regarding this product or service. I hereby release and forever discharge TLC BUTTERFLY EFFECT SPA LLC.D/B/A/ PRETTY SMILE and any other entity performing any of these services and or products provided/offered and its employees, distributors, and/or wholesalers (collectively the “vendor”) their heirs, executors administrators, successors and assigners from an and all actionable items, and I will not hold liable the above mentioned vendor for any damages, general or unforeseen, present or future, or for any adverse conditions of any type, caused directly or indirectly by the use of this product or light source. I understand that any claims, representations, and advice by TLC Butterfly Effect LLC D/B/A/ Pretty Smile professionals in regards to teeth whitening or our light source is not warranted and therefore is not guaranteed. I have read all the above declarations and consent to the use of hydrogen or carbazide peroxide and its components or light source for the use at my own risk. I understand that the use of our or any light source used is at my own discretion. I understand that in the event I fail to cancel my appointment 24-hours prior to schedule appointment a fee of $25 will be charged to resume treatments; also accept the policy that in the event of two or more scheduled treatments missed a $40 fee will charged in order to resume the packaged I purchased.
Today's Date *
Today's Date