FLOWPRESSO INTAKE FORM-A Brand New Leaf

First Name

Last Name

Address

Phone Number

Birthday

Email

Gender

Female

Male

Non-Binary

Congestive Heart Failure

Arterial Dysregulation

Carcinoma

Pulmonary Edema

Pregnant

Diabetic

Decompensated cardiac insufficiency

Deep Vein Thrombosis (DVT)

Pulmonary Embolism

Acute Inflammatory skin diseases or infection

Circulation or vascular conditions

Raynard's Disease

Severe arteriosclerosis or active infection

Surgery (in the last 12 months)

NONE OF THE ABOVE

If, surgery in the last 12 months, provide date and type or N/A

Are you currently taking any medication or receiving treatment from your doctor?

Yes

No

FLOWpresso

Informed Consent & Liability Release

By signing this Informed Consent & Liability Release, I confirm that I have provided A Brand New Leaf Wellness Center* (“The Center”) with an accurate and complete account of my health history as detailed on the previous page. I also agree to inform The Center and its employees of any changes to my health or wellness moving forward.

I acknowledge that I have received a thorough explanation of the FLOWpresso treatment program, including any potential risks or outcomes. I understand that, like any body-focused therapy, the results of this treatment may vary, and the duration required to achieve a desired outcome may differ from person to person.

I understand that this treatment is not a substitute for any medical treatments or prescribed medications from my doctor.

It is recommended that I stay well-hydrated by drinking at least 8-10 glasses of water per day before my therapy, and one glass every hour for six hours following my therapy. I also understand that reducing sugar and salt intake, eating a balanced diet, and maintaining hydration will support my body in effectively eliminating waste and may reduce potential side effects associated with lymphatic enhancement therapy.

I acknowledge that The Center is not responsible for any side effects, adverse reactions, or lack of perceived benefits that may result from this treatment. I release The Center and its employees from any and all liability in connection with the treatment.

I authorize repeat lymphatic enhancement therapies, unless I choose to revoke this consent in writing.

I understand that lymphatic enhancement therapy is not recommended for individuals who are pregnant, may be pregnant, have blood clots, deep vein thrombosis (DVT), congestive heart failure, a pacemaker, other medical-electrical implants, cosmetic implants, and/or injections (including, but not limited to, breast implants and Botox).

I have read and fully understand this Informed Consent & Liability Release in its entirety and voluntarily agree to its terms. I am aware that this is a legally binding document.

Date

Print Name

Your Signature

*

FLOWPRESSO INTAKE FORM

MEDICAL HISTORY

CLIENT CONSENT