Cavitation/Laser Lipo Consultation Form
Cavitation Lipolysis Fat cell reduction treatment (Pain free, Non invasive)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
County
Postal / Code
Home Number
-
Area Code
Phone Number
Mobile Number
Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
Date
Where did you first hear about Re-New-You Cavitation/Laser lipo treatment?
Face Book
Google
Instagram
Word of mouth
Other
I confirm I am not using any medical/electrical equipment to ibclude the following: (please mark all unless any apply)
No-Implanted cardiac pacemaker or other implanted electric device/s
No-Any life-sustaining artificial heart/lung machines or other similar equipment
No-Portable ECG measurement device
I confirm by ticking No that I do not suffer from any of the following medical conditions. I also understand, if I tick YES to any of the following medical questions, my treatment may not go ahead.
Rows
Yes
No
Any Acute Disease
Any malignacy i.e Cancer
Any infectious diseases i.e Covid
Seizure disorder or epilepsy
Cardiac problems or any known heart related diseases
Diabetes
Liver or gall bladder problems
Anorexia
Photo sesitivity
Receiving any medical treatment
High or Low blood pressure
Are you menstruating at present
Any skin conditions/infections
Pregnant or breast feeding
The treatment is fully explained in the cavitation treatment of the Removable Ink website. Please read and watch all content so you have a full understanding of the treatmet. Any questions please contact Removable Ink.
Prospective Client signature
Submit
Should be Empty: