Client Treatment Consent Form
I duly authorise the practitioners of Lissy Puig LTD to perform the procedure of
Lipo
for the purpose of spot fat reduction / improving the appearance of cellulite/ face and body skin tightening. I am aware that clinical results may vary depending on individual factors, including medical history, client compliance with pre/post treatment instructions, and individual response to treatment. I have been made aware that my diet and the amount of exercise I do, will have a major effect on the results of my treatments. If I do not make an effort to address my dietary requirements and exercise, I am aware that the results achieved may not be retained.
I understand this procedure involves a course of treatments. The fee structure has been fully explained and I understand that I am required to pay for a course of treatments prior to any procedures taking place.
I am fully aware that should I wish to cancel the course the outstanding treatment value is non-refundable.
The course cost is £……………………………………………
(Client initials) …………………………………………..
I certify that I have been fully informed of the nature and purpose of the procedure, expected outcomes and possible complications, and I understand that no guarantee can be given as to the final result obtained. I am fully aware that my condition is of a cosmetic concern and that the decision to proceed is based solely on my expressed desire to do so.
I understand that it is my personal responsibility to inform the practitioner of the clinic named above of any changes to my medical history during the treatment sessions for face or body and areas.
I confirm that should this occur, I shall advise the practitioner of any changes.
I consent to the taking of photographs and authorise their anonymous use for the purposes of medical audit, education, and promotion.
I certify that I have been given the opportunity to ask questions. All questions have been answered to my satisfaction and that I have fully read and understood the contents of this consent form. I understand that these questions are given regarding my safety and well-being. I have answered all questions to the best of my knowledge and happy to proceed with the treatments.