Body Contouring Consent

Name*

Birth Date*

Date

Phone*

Email*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact (Name, Phone, Relation to You)*

What are your treatment goals and/or specific appearance problems?*

Do you struggle with weight loss?*

YesNo

What diets and/or treatments have you tried in the past?*

If you are on an exercise program, which one and for how long?

What do you currently do to control your weight?*

Describe any aesthetic services you have received in the last 6 months.

Have you consumed at least 3 glasses of water today prior to treatment?*

YesNo, but I will have some now.

Please mark if you currently have or have had any of the following conditions:

Are you currently pregnant or breastfeeding?*

YesNo

Describe all surgeries and the year you received them.

List all allergies and your reactions to them.

List all medications/herbs/supplements currently or recently taken.

List any other medical or non-medical condition that may affect your treatment.

What is your skin type?*

DryOilyNormalAcne Prone

Is your skin fragile or sensitive?*

YesNo

If yes, please describe:

Do you have problems healing from injury to skin?*

YesNo

Have you ever had a cold sore?*

YesNo

Are you primarily indoors or outdoors?*

IndoorsOutdoors

Do you use sunscreen regularly?*

YesNo

If you are currently on a special diet, please explain:

How many glasses of water do you typically drink in a day?*

How many cups of coffee (or other source of caffeine) do you typically drink in a day?*

How often do you consume alcohol, and how much?*

How often do you consume fast food?*

How often do you consume soda or other sugary drinks?*

Do you use tobacco, and if yes, how often?*

Do you use illicit drugs? If yes, how often?*

What is your stress level?*

LowModerate/AverageHigh

General Understanding

I understand that Jamie Kowalski will evaluate this information to determine if I am a good fit for body contouring treatment. I understand that photographs and measurements will be taken and kept in my file. I agree that these forms have been completed fully and truthfully, to the best of my knowledge and abilities.

I understand that Jamie Kowalski uses ultrasound, laser, and radio frequency technology to perform services. I understand that payment is due in full at the time of service. I agree that compliance with recommended services and number of treatments is important to getting my desired results. I understand that lack of cooperation, failure to keep appointments, and engaging in activities noted by Jamie Kowalski as potentially counterproductive to the body may necessatate additional treatments not previously discussed.

I understand that Jamie Kowalski requires a 24 hour notice for appointment cancellation. I understand that if I am late to an appointment, I may be asked to reschedule or my treatment time may be shortened. I understand that either I or Jamie Kowalski reserve the right to cancel treatment during any session. I understand that there will be no financial refund if the session is terminated.

I understand that most services require multiple sessions to achieve desired results. Treatments such as Ultrasonic Cavitation and Laser Lipo require consumption of 2-3 liters of water per day for at least 48 hours for optimal results. Avoid alcohol, coffee, and fatty foods. A healthy diet and exercise improves results. I understand that results are not guaranteed and everyone's body responds differently to body contouring.

Risks of Treatment

By signing below, I verify that I am in good physical condition and the information documented is accurate and complete. I have no physical restriction, condition, or disability which may prevent me from receiving the prescribed skin care and/or body treatment therapies. I hereby give my consent to have the recommended procedures performed on me. I understand that certain procedure(s) elected are relatively new and little is known about their long-term safety and effectiveness. I understand that each person has a different response to body contouring.

I understand that the procedure(s) do not correct health problems, including but NOT limited to: diabetes, heart attack, stroke, high cholesterol, blood clots, lung problems, stomach, intestinal problems, bladder disease, and abnormality of the skin. I understand that this is not a medical facility and Jamie Kowalski does NOT make medical decisions. You must consult with your Primary Care Physician for medical advice.

I understand that I may need post procedure care. I will dutifully be responsible and compliant with the recommendations from Jamie Kowalski, which may include, but are not limited to: skin care products, clothing material, diet, etc.

I understand that these procedures involve risk. Risks may include, but are not limited to: redness, swelling, irritation, burns, skin reactions, etc. I must immediately report any unusual symptoms to Jamie Kowalski. Such symptoms include, but are NOT limited to: being aware of any slight nature or prominence of persistent chills, fever, redness, increased warmth, excessive bruising or swelling, etc. at the sights treated.

I have decided that the benefits of body contouring outweigh the potential for complications and all claims have not been evaluated by any regulatory board. I understand the nature of the procedure(s) and ANY and all possible risks mentioned and not limited to. I attest that I am of clear mind, competent, and not under any distress.

Alternative Treatments

It has been explained that other temporary and more permanent treatments are available to sculpt, contour, tone, exfoliate, clean, and detoxify the body. Alternative forms of management include receiving NO treatment at all. If treatment is chosen, alternative body sculpting therapies and other services offered include the following: Lipo Laser, Ultrasound Cavitation, Vacuum Therapy, Electrotherapy, Cold/Hot Wraps, Lymphatic Drainage, Teeth Whitening, Topical Skin Therapies i.e. gels, creams, oils, facials etc. Surgical options include Liposuction, Tummy Tucks, Fat Transfer, Muscle Repair, etc. I understand that risk and potential complications are associated with these and alternative forms of non-surgical and surgical treatments.

Data Release

I give my permission to use data about my treatment for research purposes. I understand that my name and personal identifying information will remain confidential unless I give written permission to disclose this information. I consent to the taking of photographs/video for documentation during my treatment(s) unless otherwise stated with written notice. These photos may be used for marketing and/or publication for the further benefit of educating the public. All attempts will be made to protect my identity.

HIPAA

The Department of Health and Human Services has established a "Privacy Rule" to help ensure that personal healthcare information is protected for privacy. The privacy rule was also created in order to provide a standard for certain healthcare providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or healthcare operations.

As a client of Jamie Kowalski's, I understand that she respects the privacy of my personal medical records and will do everything she can to secure and protect my privacy. She strives to always take reasonable precautions to protect that privacy. When it is appropriate and necessary, she will provide the minimum necessary information only to those who need my health information to in order to provide healthcare in my best interest.

I understand that I have full access to my medical records and records regarding any provided treatment. I may refuse to consent to the use or disclosure of my health information, only when provided in writing. Under this law, Jamie Kowalski has the right to refuse to treat me should I refuse to disclose my personal health information. If I chose to give consent in this document, at some future time I may request to refuse all or part of my personal health information. I may not revoke actions that have already been taken, which relied on this or a previous consent.

I understand that I have a right to review Jamie Kowalski's privacy notice, to request restrictions, and to revoke consent in writing after viewing the privacy notice.

Release of Liability

I hereby certify that I am not pregnant or nursing.

I understand that NO GUARANTEES OR WARRANTIES have been made to me regarding the outcome or any improvements to my condition due to the procedure(s) I have elected to undergo. I am paying for a service and not desired results from treatments. I have been given the opportunity to ask questions and have received satisfactory answers to those questions.

I agree to indemnify, hold harmless, and release affiliated organizations, and others acting on Jamie Kowalski's behalf of all claims, demands, causes of action, and legal liability, whether the same be known or unknown, anticipated or unanticipated. I further agree that except in the events of Jamie Kowalski's gross negligence or willful misconduct, no claims, demands, legal actions, and causes of action shall be made against Jamie Kowalski for any economic and non-economic losses of any kind.

Finally, I certify that I have read and fully understand the contents of this form and that the disclosures referred to above were made prior to my signing the form below.

NO REFUND OR RETURN POLICY. ALL SALES ARE FINAL.

I ACKNOWLEDGE THAT I HAVE HAD A FAIR OPPORTUNITY TO ASK QUESTIONS ABOUT JAMIE KOWALSKI'S PROCEDURES FOR BODY CONTOURING AND THE ALTERNATIVE TREATMENTS AVAILABLE. I ALSO ACKNOWLEDGE THAT MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION. I UNDERSTAND AND ACCEPT THE POTENTIAL RISKS AND COMPLICATIONS INVOLVED.

Signature*

Date*

Date

Body Contouring Consent Form