TORC Intake Form

Contact Information
Name *
Name
Date of Birth
Date of Birth
Phone
Phone
Address
Address
Referred by:
Health & Fitness Questionnaire
Do you currently exercise/workout?
If NO, do you wish to start an exercise regimen?
Are you using a personal trainer or have you ever?
Do you take any vitamins or supplements?
Are you on any kind of diet program?
Is our location convenient for you to make it in 2-3 day per week?
Does your spouse back your decision to take your fitness serious?
What primary parts of your body would you like to focus on? Please check all that apply.
Are you interested in stretch mark and cellulite reduction?
What are your goals with the TORC service? Please check all that apply.
TORC BODY CANCELLATION & APPOINTMENT RESCHEDULE POLICY
Please read the following and type your name below letting us know that you agree to the following policy
Please read the following and type your name below letting us know that you agree to the following policy
In the event you are unable to arrive on time for your scheduled treatment session, please contact Esteem Skin Clinic at least 24 hours in advance of your appointment. In the event you arrive more than 10 minutes late for your treatment, it may be necessary to reschedule your session for the next available time frame. No call, no show appointments or notice less than 24-hours will be counted against your treatment package sessions. Your cooperation is greatly appreciated.
TORC Consent
This consent form is designed to provide a written confirmation of such discussion by recording some of the more significant medical information given to you. It is intended to make you better informed so that you may give or withhold your consent to the proposed procedure(s).
Procedure
I understand that this treatment is not used to treat medical conditions nor does this treatment claim or guarantee relief of any medical conditions.
Contraindications
Please check to acknowledge that you have read and understand.
Risk/Benefits of Proposed Procedure(s)
Just as there may be benefits to the procedure(s) proposed, I also understand the procedure involves risks. These risks include allergic skin reaction, redness in the treatment area, irritation and swelling. In a state of dehydration, nausea may occur. It might also increase my heart rate. I have read the contraindications of the TORC device. I’ve shared my true medical conditions and medical history. I am in a healthy condition to use the device. I do not have epilepsy, paralysis, Parkinson’s disease. I am not pregnant. I do not have metallic implants in my body including pacemaker.
Acknowledgments
I have been explained the protocol and procedure of the TORC Body system. I understand that each person has a different response time. The potential benefits and risks of the proposed procedure(s), and the likely result with such treatment, have been explained to me. I understand what has been discussed with me as well as the contents of this consent form, and have been given the opportunity to ask questions and have received satisfactory answers.
Consent to Procedure(s) and Treatment
I voluntarily give my authorization and consent to the performance of the procedure(s) described above. Should any discomfort occur during the treatment, I will discontinue the session after immediately notifying the technician of any unusual sensations or skin reactions. I will not hold Esteem Esthetics liable for any skin related irritation or resulting effects of thermal heat being applied during treatment.
Payment Terms & Conditions
Payment for TORC procedures are due in advance of treatment sessions and are non-refundable.
By typing my name below I am acknowledging that I have read and understand this form.
By typing my name below I am acknowledging that I have read and understand this form.