Body Contouring Consent Form

Ultrasonic Cavitation, Radio Frequency & Laser Lipo Contraindications

If You Have ANY of these symptoms. You can not receive this treatment. Please DO NOT proceed with your consultation form or scheduled appointment in our clinic.

The procedure is not recommended for individuals below the age of 18 years.
Pregnant women, as well as epileptic individuals, should refrain from undertaking this procedure.
Individuals with conditions such as blood pressure, diabetes and cancer should not use Ultra cavitation treatment.
Individuals having metallic implants in the treatment area should not participate in the process.
The standard interval between individual Ultra cavitation treatments are 72 hours to allow enough time for the body to recover.

Signature*

Name*

First NameLast Name

Email*

example@example.com

Cell Phone Number*

Area CodeCell Phone Number

What areas would you like to work on?*

What are your body goals?*

Briefly describe what would you like to achieve with body contouring treatments.

All program pricing and packages are individually recommended during your consultaiton.