U&I Spa Inc

130 West 57th Street, Suite 14A
New York, NY, 10019
Phone: 917.214.9910
Email: uandispa@gmail.com

Please answer all questions below and press the [SUBMIT] button on all forms.

1. CLIENT MEDICAL HISTORY FORM

*Do you have or previously had the following? Select YES or NO
I agree that all the above information is true and accurate to the best of my knowledge.

2. STATEMENT OF CONSENT AND RECITALS:
Please read and initial all lines

I. I understand that a certain amount of discomfort is associated with this procedure, and that swelling, redness and bruising may occur.
II. I understand that tanning beds, pools, some skin care products and medications can affect my skin.
III. I have been quoted the cost of today’s procedure, and the cost of next procedures.
IV. I release the practitioner of any and all liability for any harm that may unintentionally occur during my treatments(s).
V. I understand that the anticellulite treatment that I am given is for the purpose of cellulite reduction and improving circulation. I understand that a technician neither diagnoses illness, disease, or any other medical, physical or mental disorders, nor performs any spinal manipulations. I’m responsible for consulting a qualified physician for any physical ailment I may have.
I certify that I have read and have had read to me to consents of this form. I understand the risks and alternatives involved in this procedure(s). I have had the opportunity to ask questions, and all of my questions have been answered. I acknowledge that I have reviewed and approved the material given to me, and I authorize my Specialist / Technician to perform on my body the Anticellulite treatments (by vacuum cupping and bamboo sticks) procedure desired today.
Please be aware that discounted offers (Groupon, Living Social, Gilt, Class Pass etc) are only for first time clients (one-time use). All services in this package of up to 3 sessions will expire after 6 months from purchase date. All services in the package of 6-8 sessions will expire after 1 year from purchase date.

3. PHOTOGRAPHY RELEASE CONSENT

We would like your permission to use these photos for advertising. For example: Portfolios, online and print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising.