Cavitation_Radio Frequency Consent Forms

Cavitation Radio Frequency Intake Form
General Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone#*
Email*
example@example.com
Occupation
Emergency Contact Name
Phone#
How did you hear about us?

	Measurements
Weight
Height
Waist
Hip
Right Thigh
Left Thigh
Right Bicep
Left Bicep

Cavitation Radio Frequency Consent Form
I give my consent for cavitation/radio frequency to be performed by
Please read and initial each of the statements below:*

I certify I am over the age of 18.I have voluntarily elected to receive cavitation/radio frequency after the nature and purpose of this treatment have been explained to me.I understand that cavitation/radio frequency can be used to reduce fat deposits but is not intended to be a weight loss solution.I understand that there are no guarantees that the treatment will be effective and that to ensure maximum results, multiple treatments will be necessary.I understand that the following conditions preclude me from having this treatment at this time and verify that none of the following conditions apply to me at this time:
- Cardiac issues
- Metallic implant (pacemaker)
- Cancer
- Pregnant/Lactating
- Infected, inflamed, or swollen skin
I recognize there are no guaranteed results.I understand and acknowledge that there are risks involved with the treatment I will be receiving including, but not limited to: • Redness • Headache • BruisingI have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.I have, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

Consents
I hereby grant and authorize Lancaster’s Luxe Lashes the right to take, edit, alter, copy, exhibit, publish, distribute and make use of any and all pictures, video, and/or audio is taken of me to be used in and/or for any lawful promotional materials including, but not limited to, newsletters, flyers, posters, brochures, advertisements, press kits, websites, social networking sites, and other print or digital communications without payment or any other consideration. This authorization extends to all languages, media, formats, and markets now known or later discovered. I waive the right to inspect or approve the finished product wherein my likeness appears, including a written or electronic copy. Additionally, I waive any right to royalties or other compensation arising or related to the use of my image or recording. I hereby hold harmless and release Lancaster’s Luxe Lashes from all liability, petitions, and causes of action which I, my heirs, representatives, executors, or any other persons may make while acting on my behalf or on behalf of my estate.
By signing below I knowingly and willingly consent to release any and all liability for the unintent ional exposure or harm due to COVID- I9.

By signing below, I agree to the following:
I have completed t his form to the best of my ability and knowledge. I agree to inform the technician of any changes in the above information. I agree that I do not have any cond ition(s) that would make the requested treatment unsuitable. I will inform the technician of any d iscomfort I may experience at any time during my treatment to allow them to adjust
accordingly. I agree to waive all liability toward my technician and the salon for any injury or damages incurred due to any misrepresentation of my health.

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries. losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.
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Cavitation Radio Frequency Aftercare Instruction
- Drink l.5L of water after your treatment.
- Eat a low-calorie, low-carbohydrate, low-fat, and low-sugar diet 24-hours after your treatment.
- Within 2 hours of treatment, perform at least 20 minutes of cardiovascular exercise.
- Continue to do at least 20 minutes of cardiovascular exercise for the next three days.
- Drink plenty of water to assist in flushing the toxins from your body.
- Limit the consumption of sugar, alcohol, and caffeine for the best results.
- Avoid fasting and ensure you make healthy food choices by opting for whole foods and minimizing packaged and processed foods. Limit your intake of refined sugars and carbohydrates such as white bread, white pasta, cakes, etc., and focus on consuming fresh fruit and vegetables and whole grains such as brown rice, quinoa, and wholemeal bread.
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Cavitation Radio Frequency Intake Form

Medical History

Service Information

Cavitation Radio Frequency Consent Form

Consents

Cavitation Radio Frequency Aftercare Instruction