Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
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Month
-
Day
Year
Date
Gender
Male
Female
I acknowledge that:
I understand that Body Contouring benefits in terms of shaping the body with the use of infrared sauna, laser lipo, ultrasound cavitation, radiofrequency, vacuum therapy, or wood therapy.
I understand that Body Contouring may involve risk which includes, redness, swelling, irritation, skin reaction, or increased heart rate.
I understand that Body Contouring is not a treatment for any medical condition, nor used to relieve symptoms of any medical condition.
I understand that Body Contouring is not a treatment for overweight or obesity. It is likewise not recommended that persons with such conditions undergo this treatment.
It has been explained to me that Body Contouring shall not be applied across or on the thoracic cavity, over carotid sinus nerves, inflamed, infected, or swollen areas of the skin, nor near cancerous areas.
I have been advised to take a low-fat diet and exercise in order for an effective Body Contouring treatment.
Before undergoing treatment, I have or provided my medical and health history, including any medications that I am currently taking or have taken in the past.
Further, I acknowledge that:
I understand that women during menstruation or with fever are not allowed to have treatment. As such, appointments can be rearranged on a later schedule.
I understand that pregnant or intending to be pregnant are not allowed to undergo Body Contouring treatment.
By signing this form, I declare that I am of legal age and give my full consent to the Body Contouring treatment. I have fully read and understand the contents provided herein and I assume the risks involved, including any complications and benefits resulting from the foregoing. I have had the opportunity to ask questions and clarifications and by which I have received answers to my satisfaction. I am executing this consent with full knowledge and responsibility to my actions.
Representative
I am the Legal Guardian/Representative of the above-named individual and I am executing this consent as instructed by him/her on his/her behalf.
Name of Legal Guardian/Representative
First Name
Last Name
Signature of Legal Guardian/Representative
Date Signed
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Month
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Day
Year
Date
Signature
Date Signed
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Month
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Day
Year
Date
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