NX Sculpt — Consent Form

Client Information

Full Name *

Date of Birth *

Phone *

Email *

Health History

Health conditions or concerns:

Contraindications & Treatment Limitations

I understand that treatment may be modified, postponed, or refused based on my condition.

General contraindications: Treatment will not be performed in cases of fever, infectious diseases, acute inflammation, open wounds, bruises, or severe undiagnosed pain.

MYOFASCIAL RELEASE (MFR)

Please indicate the areas where you feel pain, tension, tightness, or discomfort.

Front

Back

Left Side

Right Side

MFR: Affected Areas

Front Back Left Side Right Side

Describe the areas and the type of pain, tension, or discomfort

LYMPHATIC DRAINAGE (MLD)

Please indicate the areas where you feel swelling, heaviness, or discomfort.

Front

Back

Left Side

Right Side

MLD: Affected Areas

Front Back Left Side Right Side

Describe the areas and the type of sensation

Client Requirements & Responsibility

Preparation: I confirm that I have not consumed alcohol in the past 24 hours, I am hydrated, and I am wearing appropriate clothing.

Medical Disclosure: I confirm that I have fully and truthfully disclosed my complete medical and health history, and that I have informed the practitioner of any medical conditions, medications, allergies, or ongoing treatments.

Post-Treatment: I am responsible for following aftercare instructions, monitoring my body's response, and seeking medical guidance if unusual symptoms arise. Failure to follow instructions may increase the risk of adverse effects.

Client Signature *

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Client *

Practitioner Signature *

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Practitioner *

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